Children and Youth MPC Participation and Permissions Form 2025-2026
Please complete one form for the entire family. There are three available spots for children's names. All emails given will be added to our children and youth mailing lists, which will provide you with direct personal emails and monthly newsletter emails.
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Child First and Last Name *
Grade *
School Name
Birthday
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Any medical and personal information you would like us to be aware of? (e.g. allergies, food needs, diabetes, seizures, asthma, injuries, heart condition, surgeries, anxiety, depression, ADHD, life transitions, trauma, etc.) *
Child First and Last Name #2
Grade
School Name
Birthday
MM
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DD
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YYYY
Any medical and personal information you would like us to be aware of? (e.g. allergies, food needs, diabetes, seizures, asthma, injuries, heart condition, surgeries, anxiety, depression, ADHD, life transitions, trauma, etc.)
Child First and Last Name #3
Grade
School Name
Birthday
MM
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DD
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YYYY
Any medical and personal information you would like us to be aware of? (e.g. allergies, food needs, diabetes, seizures, asthma, injuries, heart condition, surgeries, anxiety, depression, ADHD, life transitions, trauma, etc.)
Parent/Guardian First and Last Name *
Parent/Guardian Phone (with permission to text)
Parent/Guardian Email (with permission to email)
Parent/Guardian First and Last Name #2
Parent/Guardian Phone #2 (with permission to text)
Parent/Guardian Email #2 (with permission to email)
Family mailing address (for possible cards, invitations, etc.)
Other Relative/Friend emergency contact Name, Phone, and Relationship to Child:
Massanutten Presbyterian Church Media Release: I hereby give Massanutten Presbyterian Church the permission and rights to publish, reproduce, or otherwise use my child(ren)’s voice and likeness in photographs, motion pictures, and audio-visual recordings made in connection with church activities. NOTE: Photographs of minors WILL NOT be identified by name! *
YOUTH FAMILY ONLY - Permission for off-site church sponsored activities:  I give permission for my child(ren) to accompany Massanutten Presbyterian Church and its various youth groups and/or classes for off-site events with the understanding that only adults will drive youth, and all drivers and passengers shall wear seatbelts. No youth may drive youth at any time. Should the church van be used, only drivers on the MPC approved driver list will be permitted to operate the vehicle. 
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YOUTH FAMILY ONLY - Medical Authorization and Release of Liability: I/We, the parent(s)/legal guardian(s) of the name(s) listed above, a minor child/minor children who reside(s) with us, do hereby authorize that child/those children to participate in the Youth programs sponsored by the Massanutten Presbyterian Church of Penn Laird, VA. Recognizing the possibility that physical injury may occur through participation in the various activities sponsored by the Church, we do hereby release, discharge, agree to hold harmless, and agree to indemnify Massanutten Presbyterian Church of Penn Laird, VA, its employees, its agents, its volunteers, its sponsors, and any associated personnel from any and all liability, claims, demands, or causes of action arising from the child’s/children’s participation in the youth programs sponsored by Massanutten Presbyterian Church, specifically including any and all claims for personal injuries sustained while present or participating in said programs or traveling to or from events sponsored by or in conjunction with youth programs sponsored by said Church. In the event of injury or illness to said child/children, we do hereby authorize any acting Minister, any acting Director of Youth Ministries, any acting Children and Youth Program Director, or any acting Leader and Chaperone at Massanutten Presbyterian Church of Penn Laird, VA (after a reasonable attempt has been made to reach a parent or guardian to obtain consent, or if sound medical practice decrees that there is not time to make such an attempt) to seek medical treatment for said child/children; to consent to any medical examination, x-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care, to be rendered to the minor child/children by any physician duly licensed to practice; and do consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care, to be rendered to the minor child/children by any dentist duly licensed to practice. We do further agree to be directly responsible for the payment of any charge incurred for or on behalf of the minor child/children and to reimburse Massanutten Presbyterian Church of Penn Laird, VA, for any expenses or costs advanced on behalf of said minor child/children by any Minister, Director of Youth Ministries, or Leader/Chaperone.
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YOUTH FAMILY ONLY - Medicine Permissions: In the event over the counter medication may be needed, I give permission for the following to be administered in the appropriate dosage as indicated on packaging:
Would you also like to be added to our general church mailing list for our weekly "Blessings" email?
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Parent/legal Guardian Signature (please type name): *
Date: *
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