2025 NCYC Adult Registration | Diocese of Jefferson City

NCYC 2025 Adult Participant Registration (Chaperone)

Registration for individual participants for NCYC 2025.

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This field is for validation purposes and should be left unchanged.

NCYC Group(Required)

Name(Required)

Prefix First Last

Parish(Required)

Gender(Required)

Date of Birth(Required)

Sweatshirt size(Required)

Home Phone Number

Cell Phone Number(Required)

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Ethnicity(Required)

What is your primary language(Required)

Emergency Contact Name(Required)

First Last

Phone(Required)

Relationship to Registering Participant(Required)

Relative, Parent/Guardian, etc.

Accessibility needs at the conference

To help us prepare for NCYC please check all that apply involving allergies and/or health concerns(Required)

Not applicable

Food allergies

Environmental Allergies that could impact NCYC experience

Other health concerns that could impact the trip

Please list allergies or health concerns

I am Virtus compliant(you will be notified if not)(Required)

Must be compliant by September 22, 2025 to chaperone.

Diocesan Pastoral Conduct(Required)

I will not smoke or use tobacco products in the presence of youth during the trip

I will not use, possess or be under the influence of alcohol during the trip

I will not use, possess or be under the influence of illegal drugs at any time during the trip

I will not use profanity at any time in the presence of the youth during the trip

Please check each box as acknowledgment of receipt

I will adhere to the Diocesan Pastoral Code of Conduct from drop off Thursday November 20 until pick up Sunday November 23.

Pastoral Code of Conduct

I have read statement above and understand it.

Please verify by typing your initials here:

Each parish group will have at least one copy of the medical and contact information for each participant, both youth and adult chaperone. In case of an emergency, I will notify our parish coordinator and the Diocesan Core Team.

Consent(Required)

I have read statement above and understand it.

Please verify by typing your initials here:(Required)

As a chaperone, I am responsible for the safety of the youth. I will communicate, enforce and check on the youth in my care.

Consent(Required)

I have read statement above and understand it.

Please verify by typing your initials here:(Required)

Youth Safety(Required)

Youth will always travel in groups.

All youth are in their assigned hotel rooms each night by curfew.

All youth follow curfew hours from 11 p.m. to 5 a.m.

Boys and girls gather together only in public locations, not hotel rooms or behind closed doors.

Swimming pools shall not be authorized for access by any Diocesan participants.

Please check each box as acknowledgment of receipt.

Room charges(Required)

Any purchases at the hotel concessions/restaurants must be paid for at the time of purchase.

Long distance phone calls on the hotel phone, pay-per-view TV and room service is strictly prohibited.

Charging to the hotel room is strictly prohibited and will be communicated to the youth. Any incidentals incurred by youth or chaperones shall be reported immediately to the Diocesan Core Team.

Consent(Required)

I have read statement above and understand it.

Please verify by typing your initials here:(Required)

I acknowledge receipt of the information provided describing the planned activity.

Consent(Required)

I have read statement above and understand it.

Please verify by typing your initials here:(Required)

I acknowledge that the Diocese of Jefferson City is using a charter bus service is providing transportation to and from the event/activity. I acknowledge and assume the risk of this transportation. I will comply with the Diocese and the parishes rules and procedures. I also waive any claims against, and RELEASE AND HOLD HARMLESS AND INDEMNIFY, the Diocese of Jefferson City, the parish and any of its and/or their religious, employees, volunteers, agents and representatives from any liability, claims, demands and causes of action and claims arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my participation in the event/activity, including transporting to and from the event/activity.

Consent(Required)

I have read statement above and understand it.

Please verify by typing your initials here:(Required)

Participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Office of Youth and Young Adult Ministry, the Diocese of Jefferson City and parishes of the Diocese of Jefferson City (collectively "Diocese"). Participants would not be identified, however, without written consent. Please note that the Diocese/parish has no control over the use of photographs or film taken by media that may be covering the event. I hereby expressly assign to the Diocese, and it's agents, all the rights, title and interest in, and to all the photographs/video recordings/audio recordings made by such in which I appear and/or my voice is used in and in connection with the video recording of this event. I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or any distribution of said photographs/video recordings/audio recordings without limitation for any purpose whatsoever; and I further waive all rights to any compensation for my appearance or participation in the photographs/video recordings/audio recordings.

Consent(Required)

I have read statement above and understand it.

Please verify by typing your initials here:(Required)

I fully understand the foregoing statements and sign this Consent Form, Liability Waiver and Medical Consent knowingly, freely and willingly.

Consent(Required)

I have read statement above and understand it.

Chaperone eSignature

By typing your full name you are verifying that you have personally read and agreed to this registration. Your full name will serve as your e-signature

NCYC 2025 Adult Participant Registration (Chaperone)

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