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Home
Contact Us
Our Churches
Contact Parish Office
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On Mission for the Church Alive!
Living Your Faith
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Baptism
Reconciliation
Marriage
Eucharist
Confirmation
Anointing of the Sick
Holy Orders
Request a Sacramental Certificate
Prayer & Resources
Lamb of God Chapel
Mass Intentions
Funeral Services
Mass & Reconciliation Times
Prayer Request
Pittsburgh Catholic Online
Annulment Advocacy
Faith Formation
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Religious Education
Youth Ministry
Rite of Christian Initiation of Adults (RCIA)
Ministries
Community Life
Book Discussion Group
Collection Counters
Councils
Hospitality & Events
Marriage Ministry
MOMS (Ministry of Mothers Sharing)
Respect Life Committee
St. Francis Community Garden
Technology Ministry
Two’s Together
Growing in Faith
Lectures/Events
Library
Liturgy of the Hours
Cursillo Movement
Emmaus (Men)
Emmaus (Women)
Lectionary Study Group
Prayer Ministry
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Mens Group
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Outreach
Angel Tree
Blood Drive
Hearts with Hammers
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Knights of Columbus
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Marthas
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Appalachia Teen Registration Form
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Appalachia
Appalachia Teen Registration Form
Appalachia Adult Registration Form
Rite of Christian Initiation of Adults (RCIA)
The maximum number of form submissions has been reached. This form is currently not available.
If you will be 18 years old by July 7, 2020, please fill out the Adult Registration Form. If not, complete this form.
First Name
REQUIRED
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Please enter valid data.
Last Name
REQUIRED
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Please enter valid data.
Age as of July 7, 2019
REQUIRED
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Please enter valid data.
Gender
REQUIRED
Male
Female
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Student Phone Number
REQUIRED
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Please enter a phone number.
Student Email
REQUIRED
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Please enter an email address.
Parent Email
REQUIRED
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Please enter an email address.
Participant's Address
REQUIRED
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Address 2
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City
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State
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Zip
REQUIRED
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Current Grade (as of 2019-2020 school year)
None
8th
9th
10th
11th
12th
T-shirt Size (adult unisex)
None
S
M
L
XL
XXL
XXXL
Are you a member of St. Thomas More/St. John Capistran Parish?
None
Yes
No
How many times have you attended the Appalachia Mission Trip with STM?
REQUIRED
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Please enter valid data.
Are you interested in assisting with daily Mass?
No
Eucharistic Minister
Lector
Altar Server
Coordinator
Are you interested in assisting with music? If so, which instrument?
Please enter valid data.
Agreements
I have reviewed the Dates and Deadlines section of this website and I am able to attend all meetings.
It is expected that ALL teens will attend and actively participate in the mission work for the entire duration of the trip.
It is expected that ALL teens will participate in at least two of the various fundraising activities scheduled throughout the year.
By signing this form, I agree that I will complete any additional forms, comply with all parish program policies, attend mandatory meetings, and fulfill my assigned work tasks on the trip.
I understand that if I am unable to meet these requirements, I will be unable to participate in the mission trip.
Code of Conduct
The consumption or possession of alcoholic beverages, cigarettes, any tobacco products, or illegal drugs is prohibited.
The consumption or possession of any prescription drugs that have not been disclosed on the medical release section below is prohibited.
Adherence to all regulations is expected of all participants. This includes, but is not limited to: modest dress, full participation in all activities, respect of curfew and meeting times, and appropriate conduct in relationships with the opposite sex.
Respect of property, tools, home owners, adult leaders, participants, and staff of Bishop Hodges Pastoral Center is expected of all participant.
Disrespect or mistreatment of other participants is not permissible. Additionally, participants are not permitted to exhibit public or private displays of romantic affection deemed inappropriate by adult leaders.
Cost Expectations
I understand the cost per person of this trip is $400. To secure my spot I will submit $100/individual ($200/family) to Karen (made out to STM) by 10/31/19. I understand that I must fund raise or pay the remaining balance by 6/5/20.
Student Signature
Please enter valid data.
I understand the above expectations and consequences as they have been set forth by the staff of St. Thomas More. I will obey these rules and any others made before and/or during the trip.
Parent Signature
Please enter valid data.
I understand the above expectations and consequences for my child as have been set forth by the staff of St. Thomas More. I understand that if my child does not comply, they will incur the aforementioned consequences. I agree to all of the above, and if my child should be dismissed from the trip, I will make arrangements to pick them up within 12 hours.
Today's Date
Please enter valid data.
The Appalachia Mission Trip has my permission to use my/my child's photograph publicly to promote the Appalachia Mission Trip. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Agree
Medical Release Information
I/We, the parents/guardians of the above mentioned child, for myself/ourselves and for my/our child, give permission for my/our child to participate in the Appalachia Mission Trip on July 7-12, 2020.
In the event of any injury or illness to my/our child during his/her participation in this event, I/we hereby give my/our permission for the necessary medical treatment to my/our child. I/We agree that in case of injury to my/our child, I/we will not look to St. Thomas More Church or the Roman Catholic Diocese of Pittsburgh for the payment of any medical costs or injury-related costs.
Agree
Liability Release:
In consideration for being accepted by St. Thomas More for participation in this event, we(I), being 21 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless St. Thomas More Roman Catholic Church and the Diocese of Pittsburgh, thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant while said child is participating in the above described event. Furthermore, we (I) (and on behalf of our (my) child –participant if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to St. Thomas More to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify St. Thomas More, and its employees and agents, for any liability sustained as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant there to. (If the participant has not attained the age of 21 years): We(I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in said event and hereby give our(my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and will assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we(I) hereby assume all transportation costs.
Agree
Date of Last Tetanus Shot (Year)
REQUIRED
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Please enter valid data.
Health Insurance Company
REQUIRED
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Please enter valid data.
Policy Number
REQUIRED
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Please enter valid data.
Emergency Contact Name
REQUIRED
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Emergency Contact Phone Number
REQUIRED
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Please enter valid data.
Treatment Release
I/We the undersigned parents/guardians of the abovenamed child hereby authorize treatment of my/our child by a licensed medical professional in case of any accident, illness or emergency that may so arise, or any hospitalization necessary.
I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
Of the following statements pertaining to medical matters, check ONLY those boxes in accordance with your wishes:
My child is taking medication at present. My child will bring all such medication necessary, and such medication will be well-labeled. My child will administer his/her own medication.
I hereby grant permission for non-prescription medications (such as Tylenol, throat lozenges, cough syrup, etc) to be given to my child, if deemed advisable.
No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.
Disclosure of Prescription Drugs
Any known allergies?
Any physical limitations or work restrictions?
Any medically prescribed dietary needs?
Participant Signature
REQUIRED
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Please enter valid data.
Parent/Guardian Signature
REQUIRED
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Today's Date
REQUIRED
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