YOUTH MINISTRY REGISTRATION
LIABILITY RELEASE AND MEDICAL INFORMATION
CHILD PARTICIPANT INFORMATION - FULL NAME *
Grade ___ Age ___ Date of Birth *
Baptismal Name ___ Name Day
MINISTRIES IN WHICH YOU WOULD LIKE TO PARTICIPATE. Please, checkmark those that apply. *
Required
PARENT / GUARDIAN INFORMATION
I understand that participation in the above youth ministry groups will involve social events and/or outdoor activities, on
and off the premises of St. Barbara Church, any of which could possibly lead to physical injury to my child, even caused
by the negligence or carelessness of advisors, chaperones, drivers, participants or volunteers of St. Barbara Greek Orthodox Church, or their agents (referred to as the “Sponsors”). In consideration of permitting my child to participate in these
activities, however, I agree to the following:

1. I agree to assume all risks of injury to my child. I understand that travel and participation in some athletics may result in severe injury, including paralysis, or death.

2. I agree to hold harmless and indemnify the sponsors, the officers and members of the parish council, all employees,
agents, and stewards of the St. Barbara Greek Orthodox Church, of any and all liability in connection with any activity
described hereinabove that my child participated in, which may result in any injuries of any kind to my child.

I hereby authorize the Sponsors to obtain, through a physician of their own choice, any emergency care that may become
reasonably necessary for the student in the course of activities or travel. Payment of all charges incurred for medical
treatment is guaranteed by me or the insurance company providing coverage for the above-named child.

I hereby certify that I have read this form and understand the rules contained herein and that the
information supplied is true and correct to the best of my knowledge. I accept the responsibility to inform the Sponsors
of any future change of this information.
Parent / Guardian Name *
Street Address__City__State__Zip Code *
Phone Numbers__Mobile__Land line *
E-mail address
In case parent /guardian cannot be contacted, please provide the information of another family member or a trusted person that we may contact
Full Name__Relationship *
Phone Number of the trusted person. *
HEALTH INSURANCE AND MEDICAL INFORMATION
Required as part of registration for all Youth Ministries and activities.
Personal Medical Insurance Company *
INSURANCE COMPANY ADDRESS: Street__ City__State__Zip Code *
Name of Covered Insured *
Insurance Policy# ___ Identification Number of Insured *
Current medications *
List any allergies *
List any sensitivities ___ List any limitations *
Is the child affected by the following illnesses? *
Required
If any other medical problems, please list below: *
PHOTO AND VIDEO RELEASE
Representatives and authorized contractors of the Church are hereby authorized to take and record photographs, videotape or other images, and or make an audio, video or other recordings, of Participant and Participant’s activities at or involvement in Church Events, or using Church Property and Equipment, solely for use by the Church in its brochures, newsletters, videotapes, recordings, web sites, and other promotional material or items to promote the Church or Church Events, all without any remuneration to Participant, Guardian or the Undersigned of this form.
PLEASE, TYPE YOUR NAME BELOW as an acknowledgment that the information you provided is correct and you agree with the requirements and stipulations of this form *
DONATIONS / TUITIONS
All donations for the Church School or, tuitions for Helenic Fork Dancers and Greek Language School will be send by mail or made in person to the Chairperson / Instructor or Principal
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