Aldersgate Youth Group Registration 2017-2018
Household Information
Parent/Guardian 1
First & Last Name
Your answer
Relation to Child(ren)
Your answer
Phone Number
Your answer
Phone Type
Alternative Phone Number
Your answer
Email Address
Your answer
I would like to be added to the weekly church email list
Home Address
Your answer
Parent/Guardian 2, if applicable
First and Last Name
Your answer
Relation to Child(ren)
Your answer
Phone Number
Your answer
Phone Type
Alternate Phone Number
Your answer
Email Address
Your answer
I would like to be added to the weekly church email list
Home Address if different from above
Your answer
Other safe adults who are authorized to pick up your child(ren), if any
Your answer
Insurance Information
Insurance Co.
Your answer
Insurance Co. Phone Number
Your answer
Policy Number
Your answer
Group/Plan Number
Your answer
Policy Holder ID Number
Your answer
Doctor Name
Your answer
Doctor Phone
Your answer
Student Information
Participant 1
Name of student
Your answer
Birthdate of student
MM
/
DD
/
YYYY
Grade for 2017-2018 School Year
School attending
Your answer
Please list any allergies, medical conditions, or learning or psychological differences, as well as how we can best equip your child (this information is confidential). If none, enter "none."
Your answer
Date of last tetanus shot
Your answer
Participant 2
Name of Student
Your answer
Birthdate of Student
MM
/
DD
/
YYYY
Grade for 2017-2018 School Year
Name of School
Your answer
Please list any allergies, medical conditions, or learning or psychological differences, as well as how we can best equip your child (this information is confidential). If none, enter "none."
Your answer
Date of last tetanus shot
Your answer
Participant 3
Name of Student
Your answer
Birthdate of Student
Your answer
Grade for 2017-2018 School Year
Name of School
Your answer
Please list any allergies, medical conditions, or learning or psychological differences, as well as how we can best equip your child (this information is confidential). If none, enter "none."
Your answer
Date of last tetanus shot
Your answer
Liability Release
I understand that by participating in Aldersgate activities, my child may engage in various games, activities, and service projects. These activities may include transportation by a qualified adult. Proper safety precautions will be taken for all activities.

In consideration of accepting these activity and/or transportation services, I hereby for myself and heirs, waive any and all rights and claims for damages I may have against Aldersgate UMC and its representatives, for any and all injuries from whatever cause suffered by the below child(ren) in the course of the activity or transportation service provided. In the case of an emergency, Aldersgate UMC representatives have my permission to use their judgment with regard to treatment until I can be contacted.

Name of Participant
Your answer
Name of Participant 2
Your answer
Name of Participant 3
Your answer
Name of parent or guardian (by entering my name, I acknowledge and agree to the above liability release)
Your answer
We take pictures and videos of students doing projects or activities from time to time, and use them for slides, videos, and other promotional materials, which may include social media. Do you give Aldersgate United Methodist Church the rights to use images of your child for these purposes?
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