PCW Youth 2019/2020 REGISTRATION FORM

This registration form is to be completed ONCE for use during the September 2019 - August 2020 Program Year at The Presbyterian Church in Westfield for students in grades 6-12 for ALL PCW Youth events/retreats/trips and programs.

1. Your information WILL NOT be shared with anyone other than PCW Youth STAFF.
2. If an email address is listed, we will add it to our PCW Youth (only) email distribution list to receive pertinent information regarding just PCW Youth activities, events, and programs, including but not limited to schedule changes, special youth events, parent messages, etc. You may unsubscribe at any time.
3. Make sure to click SUBMIT at the end of the form.
4. You only need to submit this form ONCE for the entire year for all programs, retreats and events.
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    Student Information

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    Parent/Guardian Contact Information

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    EMERGENCY CONTACT INFORMATION

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    Physician Contact Information

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    IMMUNIZATION HISTORY

    Please enter the dates below. Approximate dates are OKAY. If possible, please submit an immunization list from the physician to the church office.

    HEALTH HISTORY

    Good health
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    DIETARY NEEDS

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    Medical Insurance Information

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    Please read the following statements and initial, if you agree.

    I/We give permission for my child to participate in The Presbyterian Church in Westfield’s Middle School and/or High School ministries weekly meetings, activities, and trips during the year 2019/2020. I/We wish to make clear our understanding that The Presbyterian Church in Westfield is hereby relieved from any liability for loss of property, damage to property, or any personal harm that may come to the participant, and absolve The Presbyterian Church in Westfield, and hold it harmless from any claim or demand which might be asserted in connection with these meetings, activities, and trips. In case of a medical emergency, I/We hereby authorize any medical and/or surgical care, including diagnosis and treatment, to be given by any licensed hospital or clinic, when the participant is accompanied by an adult leader and efforts have been made to contact the participant’s parents. I/We assume full responsibility for such care. As a participant, your child’s image, name, and voice, as well as any presentation, speech, or written document submitted by him/her, may be used, reproduced, distributed and/or modified by The Presbyterian Church in Westfield at any time in a variety of media for a variety of purposes including, but not limited to, print, video, photographs, all of which may be available on the Internet. By clicking submit below you indicate that you have read and understand the terms and conditions of this 2019/2020 Registration Form. Also, you authorize medical care for your son/daughter in the event of an illness, injury and/or emergency.
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