Youth Information Form 2018-2019
To be completed by Parent / Guardian with Student Input.
Email address *
Be Sure to Fill Out This Form in its Entirety and Click SUBMIT at the End.
Once submitted you will receive an emailed confirmation.
Please Select from the Following: *
Required
Student Information
Name: *
Your answer
Grade: *
Gender:
Date of Birth: *
MM
/
DD
/
YYYY
T-Shirt Size (adult sizing):
Student Cell Phone:
Your answer
Student Email (only if you check it regularly):
Your answer
Street Address: *
Your answer
Do you sing or play an instrument?
If so, what do you play?
Your answer
Are you in any music or theater groups?
If so, what groups?
Your answer
Do you play any sports?
If so, what sports?
Your answer
Are you in any clubs at school?
If so, what clubs?
Your answer
Name two hobbies, or things you like to do for fun:
Your answer
Parent / Guardian Information
Parent or Guardian #1 Name: *
Your answer
Parent or Guardian #1 Email Address: *
Your answer
Parent or Guardian #1 Cell Phone: *
Your answer
Parent or Guardian #1 Other Phone:
Your answer
Parent or Guardian #1 Address (if different from Student):
Your answer
Parent or Guardian #2 Name:
Your answer
Parent or Guardian #2 Email Address:
Your answer
Parent or Guardian #2 Cell Phone:
Your answer
Parent or Guardian #2 Other Phone:
Your answer
Parent or Guardian #2 Address (if different from Student):
Your answer
Emergency Contact Information
If parents / guardians cannot be reached, please contact:
Contact #1 Name: *
Your answer
Relationship: *
Your answer
Contact #1 Cell Phone:
Your answer
Contact #1 Other Phone:
Your answer
Contact #2 Name:
Your answer
Relationship:
Your answer
Contact #2 Cell Phone:
Your answer
Contact #2 Other Phone:
Your answer
Permission for Youth Activities
As the parent or guardian of the student named above, by initialing below, I give my child permission to attend Youth Activities sponsored by First Church, Simsbury, between July 1, 2017 and July 31, 2018. I understand that these activities will be supervised by Rev. Kevin Weikel, Associate Minister for Youth and Young Adults, and/or appointed adult leaders of the Youth Groups. I agree to give emergency information to the adult in charge if it is different from the information submitted on this form.
Initials:
Your answer
Today's Date:
MM
/
DD
/
YYYY
Publication Release
As the parent or guardian of the student named above, by initialing below, I authorize First Church, Simsbury, to use pictures of my child for church- related publications.
Initials:
Your answer
Today's Date:
MM
/
DD
/
YYYY
Medical Consent
As the parent or guardian of the minor named above, by initialing below, , acknowledge that this form is filled out to the best of our ability and do hereby authorize Rev. Kevin Weikel, Associate Minister for Youth and Young Adults, and/or appointed adult leaders of the Youth Groups as agent(s) for the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment or hospital care which is rendered under the supervision of any physician, surgeon, or dentist whether diagnosis and treatment is in a hospital or office of said physician. . It is understood that this consent applies only in a situation where a parent / guardian is unable to be reached or consulted with in a timely manner.
Initials:
Your answer
Today's Date:
MM
/
DD
/
YYYY
Family Physician:
Your answer
Phone:
Your answer
Address:
Your answer
Insurance Carrier:
Your answer
Group Number:
Your answer
Policy Number:
Your answer
My Child Has Allergies: *
Please Specify Type, Reaction, and Treatment:
Your answer
My Child has other Health Concerns/Conditions: *
Please Specify:
Your answer
My Child Takes Medications Daily: *
Please Specify:
Your answer
A copy of your responses will be emailed to the address you provided.
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