RYM Student Registration Form 2025-2026
This is the Regional Youth Ministry in Lower Fairfield County's student registration form for all members of RYM! It is effective for all RYM activities for Sep 1, 2025 - Aug 31, 2026. 

Every family will need to submit this form for each student, separately. To do this, complete the form for an individual youth and return to the original link to complete the form again for any subsequent student(s).

Please take a few moments to tell us about you and your child so we can best support them and their well-being in this fun, faith-filled, and inclusive community. This gives us all the information we might need for regular events, off-site, and overnight trips.
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Student Full Name: *
Student Preferred Name:
Chosen Pronouns: *
Student Date of Birth: *
MM
/
DD
/
YYYY
Student 25-'26 Grade:
 *
Student Cell Number: *
Student Email Address:
Student Full Home Address:  *
Student's Siblings Name(s) & Grade(s):
Student T-Shirt Size

*Youth will receive a shirt as part of their dues on Service Learning Trips. Shirts will also be provided to Youth Advisory Council members and the Advisory Committee members! Shirts are available for purchase via check or donation in all sizes when group orders are placed. Prices may vary. 
 *
Required
Parent/Guardian 1

- Name:
 *
Parent/Guardian 1

Relationship to Student: *
Parent/Guardian 1

- Cell Phone Number:
 *
Parent/Guardian 1

- Primary Email Address:
 *
Parent/Guardian 1

- Full Home Address (if different from student):
 *
Parent/Guardian 2

- Name:
Parent/Guardian 2

- Relationship to Student:
Parent/Guardian 2

- Cell Phone Number:
Parent/Guardian 2

- Primary Email Address:
Parent/Guardian 2

- Full Home Address (if different from student):
Secondary Emergency Contact (if a parent/guardian cannot be reached)

- Name:
 *
Secondary Emergency Contact

- Cell Phone Number:
 *
Secondary Emergency Contact

- Primary Email Address:
 *
Secondary Emergency Contact

- Relationship to Student:
 *
Insurance Information

- Medical Insurance Company:
 *
Insurance Information

- Name of Policy Holder: *
Insurance Information

- Policy/Group Number:
 *
Insurance Information

- Company Phone Number:
 *
Insurance Information

- RX ID Number:
 *
Insurance Information

- RX Policy/Group Number:
 *
Health Information

Please list and explain ALL health problems or chronic medical conditions. (if necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability or condition to which the student is subject and of which RYM should be aware, and what, if any, action or protection is required on account thereof.  Include names of medication and dosages that must be taken. [needed for overnight trips]) Please also include any sensory or mental health needs:
 *
Student Covenant 

Students who participate in Regional Youth Ministry (RYM) programs are expected to conform to the following rules of conduct. Students themselves must read and agree to the following expectations:

Students who participate in RYM programs shall NOT:

- Drive without proper authorization

- Possess or use alcohol, drugs, tobacco or pornography

- Possess weapons, fireworks, lighters, etc.

- Use profanity or act offensively or inappropriately

- Engage in fighting or bullying

- Wear offensive or inappropriate clothing

- Enter any sleeping quarters that are not your designated sleeping quarters

Students who participate in RYM programs SHALL:

- Engage/participate in group discussions, activities, etc.

-Respect the property of all other individuals and/or organizations involved with RYM programs

- Respect one another, staff, and adult volunteers

- Respect and comply with event schedules

- Uphold an environment that affirms LGBTQIA+, People of Color, differing beliefs, abilities, and identities, and fosters respect, safety, and belonging for all youth

 *
Student Signature (type full name):

(ONLY to be signed by the student)
 *
Parent/Guardian Consent

I give permission to Regional Youth Ministry in Lower Fairfield County to seek whatever medical attention is deemed necessary and release Regional Youth Ministry (hereinafter "RYM"), and all RYM Covenanted Partners, its staff, directors, officers, employees, teachers, chaperones, volunteers, and agents from any liability for any personal losses of the named student. I/We, the undersigned, have legal custody of the student named above and have given our consent for them to attend events organized by RYM. 

By my signature, l/we acknowledge:

I/We are aware that activities may include participation in sporting/recreational events. (Note: if you desire to limit your student's participation in any event, please submit your wishes in writing to the Director of Regional Youth Ministry (khaleighl@fccog.org). I/We give permission for the above-named student to be transported to and/or from RYM-sponsored events and RYM-approved meetings by: (A.) church provided transportation and/or (B.) adult-driven transportation... (RYM staff and adult volunteers will be the driver of these vehicles). It is understood that one adult may drive a group of youth to and from off-site activities and/or that one adult may be alone with a youth for a short period of time. I/We give permission for any videos or photographs taken of the above-named student to be used on the RYM website (myrym.org), in RYM publications, and/or for other uses to be determined by the RYM Director.

In the event that the above-named student is injured or should require medical or dental attention while participating in RYM-sponsored events, I/We authorize RYM representatives or sponsors of the event to secure necessary medical treatment for the above-named student. I/ We acknowledge that I/we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. I/We affirm that the health insurance information provided on this form is accurate as of the date upon submission and will, to the best of my/our knowledge, still be in force for the student named above. I/We further understand that it is solely our responsibility to notify the RYM Staff of any changes regarding the above-named student's contact, health, medical insurance, or guardianship information. I/We release, waive, discharge, and covenant not to sue Regional Youth Ministry in Lower Fairfeild County, its covenant partners, staff, volunteers, agents and/or governing bodies, for any action or causes of action, including but not limited to, personal injury, property damage, or wrongful death, which may exist or which may hereafter arise during and following the participation of the above named student in a RYM-sponsored event occurring between the dates listed on this form. I/We further understand and agree that in the event that the above-named student is involved in activities that violate or compromise the rules, policies, or purposes of RYM, I/we will accept full responsibility for removal and release of the above-named student to my/our custody and care. I/We further understand that I/we will cover all financial costs if the above-named student is sent home for disciplinary reasons. 

I/We have read and understand this form and all information provided is true and correct to the best of my/our knowledge. Unless terminated in writing that is submitted to the RYM Director, this release shall be in effect from September 1, 2025 through August 31, 2026:

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Parent Signature (type full name): *
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