Immaculate Conception Church, 113 North Geneva St, Ithaca NY 14850

Youth Group Registration

To register for the Immaculate Conception Church Youth Group, please complete the following form. You may also click here to download a copy of MS Word document of the same form and mail it to the office at:

113 N. Geneva St.
Ithaca, NY 14850

Personal Information

Name of Participant*
Phone*
Address
Town/City
Date of Birth
Emergency Contact
Phone
Health Insurance Company
Family Physician/Clinic

Please list any allergies or special needs:

Is there anything else that we should know about your child?

Authorization

In checking the "I Agree" button below, I hereby certify that the above information is correct and give permission for my child to be transported in an ambulance or privately owned behicle for medical and other emergency purposes only, and for the release of medical records to an attending physician in case of illness.

In case of medication emergency, I understand that every effort will be made to contact the parents or guardian. In the event that I cannot be reached, I hereby give permission to the physician selected to secure proper treatment for my child named herein.

I Agree I Disagree

Phone Number
Date