National Catholic

Youth Conference Indianapolis, IN November 20-23, 2013

Important Due Dates and Deadlines

Sunday, June 9 $100 Deposit and Registration Forms due

to St. Malachy Office

Tuesday, June 11 Late Registration—add $10.00

Saturday, July 20 NCYC Meeting – Participants Only

Sunday, August 18 NCYC Meeting – Parents Only

Sunday, September 8 NCYC Meeting – Parents and Participants

Final Payment Due (End of Registrations)

Sunday, October 13 LAST DAY TO CANCEL, SUBSTITUTE, OR

PAY ($50 Late Fee Applied)

Sunday, October 20 NCYC Meeting – Participants Only

Sunday, November 17 Final NCYC Meeting – Parents and

Participants

NCYC Costs and Logistics

Cost: $500 per participant

$250 per chaperone

What does it pay for? Registration fees, 3 nights at the JW

Marriot, 2 tee shirts, most meals, some

tradables, and an awesome time

Where is NCYC? Lodging is at the JW Marriot, General

Sessions are held in Lucas Oil Stadium, and

all workshops and the “Inspiration

Junction” are in the Indianapolis

Convention Center

What is the Schedule like? BUSY! Wednesday night begins with an

Arch Indy concert by Jesse Manibusen,

Thursday kicks off NCYC with mass at St.

Johns and Eucharistic Procession to the

Convention Center, and then General

Sessions, workshops, speakers, music,

“Inspiration Junction,” and best of all,

time with Jesus!

What is “Inspiration Junction”? This is the conference “thematic park”

with a variety of service projects, booths,

art experiences, coffee house, and vendors.

A lot happens here all day long!

INDIVIDUAL PARTICIPANT REGISTRATION FORM

2013 National Catholic Youth Conference

This form continues on page 2…please complete both pages.

FORM #9

OVER

Clearly Mark One: Youth Adult Priest Sister Deacon Brother .

First Name: ___________________ Nickname/Name for Badge: _________________ Middle Initial: _____

Last Name: _________________________________ Date of Birth: ___/___/______ Male Female Address: ____________________________________ City____________________ State____ Zip:________

Home Phone: (______)_________________________ Cell Phone: (______)__________________________

Email: _______________________________________ Archdiocese of Indianapolis/Region 7

Parish/School attending with:________________________________ Deanery: _______________________

T-Shirt Size: S M L XL 2-XL 3XL .

Emergency & Medical Release – Archdiocese of Indianapolis Emergency Contact Name(s): _______________________________________________________________

Home Phone: (______)________________________ Cell Phone: (______)_______________________

Health Insurance Co: ___________________________ Policy #: ___________________________________

Allergies, Dietary Restrictions or Special Needs: (If you need more space, use the back side of this form or attach another page.)

________________________________________________________________________________________

Name of Medication Dosage Frequency Reason

PARTICIPATION CONSENT:

I will not hold the Archdiocese of Indianapolis responsible in the event of any injury or accident while participating and/or traveling to and from the National Catholic Youth Conference (NCYC). I warrant that, to the best of my knowledge, I am in good health and am able to participate in all program activities. (Please indicate limitations under special needs). I

Mark Access Needs: Wheelchair Access Required Hearing Impaired Gluten Free Limited Mobility Deaf Blind/Visually Impaired (require more than contacts or glasses)

Ethnicity: Asian/Pacific Islander Black Hispanic Native American White Multi-Ethnic Other

Youth Only: Grade at time of NCYC: 9th 10th 11th 12th Mother/Guardian First & Last Name: _________________________________________

Father/Guardian First & Last Name: _________________________________________

Check box if address is different

than child’s

Adults Only: Background Check VIRTUS Training Code of Conduct (ArchIndy)

Please note: no adult will be permitted to attend/participate that has not met these requirements.

agree that I will abide by the Codes of Conduct or understand that if I have a serious infraction of the Code, I may be immediately dismissed from the NCYC with no refund, and sent home at my expense. I understand that if I am 18 or younger & in High School, my medication will remain in the possession of the adult team leader (exception: inhaler) and be dispensed as prescribed. I understand that non-prescription medication (such as Tylenol, throat lozenges, etc.) will not be available unless brought by the participant. In case of medical emergency, I understand that every effort will be made to notify the emergency contact of the participant. If treatment is necessary, I hereby give permission to the medical staff to hospitalize & secure proper treatment for me. I understand I may be photographed, unidentified in group situations; and I hereby grant permission to be photographed & identified for releases to The Criterion and/or Archdiocesan website and/or other promotions.

Participant Signature: _______________________________________ Date: ____________________ Parent/Guardian Signature:___________________________________ Date:_____________________ (Required for 18 & under and in High School)

This form (Form 9) is to be filled out by each Participant. Please return to Youth/Campus Minister by: ______________

If needed, please list additional information here: (Emergency, Medical, Allergies, Dietary, Special Needs, etc.)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FORM #10