Christ UMC Youth Ministries Registration Form
This registration is effective September 1, 2018 through August 31, 2019
Contact us at (215) 855-1643 or secretary@cumclansdale.org
Contact Information
Youth's Full Name *
Your answer
Youth's Date of Birth *
Your answer
Youth's Sex *
Your answer
Address *
Your answer
Home Phone *
Your answer
Youth's Cell Phone and Email *
Your answer
Mother/Guardian (Name, Cell Number, Email) *
Your answer
Father/Guardian (Name, Cell Number, Email) *
Your answer
If parent(s)/guardian(s) can not be reached, please list an alternate contact. Please provide their name, phone number, and relationship to youth. *
Your answer
Medical Information
Youth's Allergies *
Your answer
Youth's Medical Conditions and/or Limitations *
Your answer
Youth's Medications/dosage/time. (Please note that youth will be responsible for their own routine medications unless prior arrangements are made with adult leaders.) *
Your answer
Youth's Physician's Name and Phone Number *
Your answer
Medical Insurance Provider and Policy Number *
Your answer
Dentist's Name and Phone Number *
Your answer
Dental Insurance Provider and Policy Number *
Your answer
Student Information
Youth's Grade *
Youth's School District *
Your answer
Does your child play an instrument or have special talents? If so, please list/describe:
Your answer
Is there any information you would like to share about your child that will enhance their participation and experience in the Youth Ministry Program (Sunday School, Youth Group, Youth Music, etc.)?
Your answer
Drop Off/Pick Up and Transportation Information
Youth are not to arrive/be dropped off at a Youth Ministry classroom or activity until at least two Safe Sanctuary Adults are present onsite. After Youth Ministry classes, activities, or events, Youth, who are not transporting themselves, will need to be picked up by an adult or fellow Youth that has been pre-approved by their Parent/Guardian. This form allows parents/guardians to list three permanent people who can pick up their child after Youth Ministry classes, activities, or events. If a situation arises that someone, not on this list, will be picking up your child, please submit a signed note or email to the Youth Leader prior to the class, activity, or event.
Please list below, up to three people who may pick-up your child from a youth class, activity, or event.
Pick Up Person 1 Name and Relation to Youth *
Your answer
Pick Up Person 1 Home and Cell Phone Numbers *
Your answer
Pick Up Person 2 Name and Relation to Youth
Your answer
Pick Up Person 2 Home and Cell Phone Numbers
Your answer
Pick Up Person 3 Name and Relation to Youth
Your answer
Pick Up Person 3 Home and Cell Phone Numbers
Your answer
If your child will be walking to/from any Youth events or activities please type your name here to acknowledge that you give permission to Christ United Methodist Church staff and volunteers to release your child to walk home at the conclusion of these activities/events. (If this is left unanswered, your child will need to be picked up by an approved person.)
Your answer
Release Information
Do you give permission to Christ UMC to take photographs and video of your child for church publications, website, and social media? *
In the event of an emergency, I give the Youth Group leaders permission to secure any medical or dental treatment deemed necessary for my child from a licensed provider. I expect to be contacted as soon as possible. I agree not to hold Christ United Methodist Church, its staff or volunteers liable for any damages, losses, diseases, or injuries. (Please type your name here to indicate that you have read, understand and agree to the above statement. If there is more than one parent or legal guardian, please have each type their name.) *
Your answer
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