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2018-19 WPC Child/Youth Registration & Consent Form
Email address *
Child/Youth Name: *
Grade: *
Age: *
Birthdate: *
Home phone:
Parent or Guardian Names: *
Youth cell phone #:
Youth email address:
Primary parent cell phone # and name of parent: *
Primary parent/Guardian email address: *
Are both parents members of WPC? *
Is your child/youth baptized? *
If yes, date and place of baptism:
If one parent (guardian) has another religious affiliation, please indicate:
Student's parents are: *
Student lives with: *
Siblings and their class (or age):
Special notes, concerns, illnesses, or allergies:
Medical Insurance Company and Policy #: *
Name of Insured: *
Emergency Contact and phone # (please name 2): *
For pre-K-5th: Permission to leave Sunday School with a 6th grader or older sibling:
Clear selection
For Youth: Permission to leave after a program without an adult:
Clear selection
Permission for an adult leader to drive my youth to or from an off-site activity:
Clear selection
Permission to publish photos/videos of the aforementioned child/youth (I understand that photos/videos will only be used to enhance the communication and ministry of our congregation, such as worship, Christian Education, mission trips, youth events and other special events.
Clear selection
Authorization and Waiver: My child has permission to participate in the Christian Education and youth programs sponsored by Westminster Presbyterian Church, and any trips and special activities sponsored by such programs. In the event of illness or accident, if I cannot be reached or if circumstances require immediate action, I authorize the church and its agents to consent to any examination, treatment or medical care for my child that is deemed advisable and provided under the supervision of medical personnel. I also release the church and its agents from responsibility in the case of illness or accident in connection with church activities. I understand that providing the Medical Information above is optional, and is for the purpose of providing Westminster with information about my child's allergies, medical conditions and health insurance in the event of a medical emergency. *
Electronic Signature and Date *
It takes a village! Your help and participation in our Christian Education and youth programs is essential to their existence and functioning. Not only do you demonstrate the importance of the church and its ministry to your children and youth, but they really do like to see you! Keep an eye out for how you can help volunteer with our programs.
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