PCW Youth 2017/2018 REGISTRATION FORM
This registration form is to be completed ONCE for use during the September 2017 - August 2018 Program Year at The Presbyterian Church in Westfield for students in grades 6-12 for ALL PCW Youth events/retreats/trips and programs. If medical or any other information changes, please contact Linnette Mercado at lmercado@westfieldpc.org to update.

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.

Please CHECK ALL Programs You Wish To Register Your Student For, This Program Year (September 2017/August 2018)
If you are only registering for a specific retreat/trip/event, PLEASE CHECK OTHER AND WRITE IN THE EVENT NAME. You do not need to select other programs.
Student Information
Student Full Name (First / Middle / Last)
Your answer
Grade (2017/2018)
T-Shirt Size
Date Of Birth
Your answer
Student Cell Phone Number
Your answer
Student Email Address
Your answer
Home Address
Street Address, City, State, Zip Code
Your answer
Home Phone Number
Your answer
School Teams/Extra Curricular Activities
Rev. Amanda and the PCW Youth Staff love to spend time supporting PCW Youth at all of their games/programs.
Please List the Teams/Activities Here That Your Student is a Part of:
Your answer
Parent/Guardian Contact Information
Parent/Guardian #1 Full Name
Your answer
Parent/Guardian #1 Cell Phone Number
Your answer
Parent/Guardian #1 Email Address
Your answer
Is Parent/Guardian #1 a member of The Presbyterian Church in Westfield?
Parent/Guardian #2 Full Name
Your answer
Parent/Guardian #2 Cell Phone Number
Your answer
Parent/Guardian #2 Email Address
Your answer
Is Parent/Guardian #2 a member of The Presbyterian Church in Westfield?
EMERGENCY CONTACT INFORMATION
If Parent/Guardian is NOT available, in case of EMERGENCY, please contact:
Full Name & Relationship & Phone Number
Your answer
Physician Contact Information
Name of Physician
Your answer
Physician Phone Number
Your answer
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.
Date of Last Medical Exam
MM
/
DD
/
YYYY
Date of DPT/Tdap/Tetanus Shot/Booster
MM
/
DD
/
YYYY
HEALTH HISTORY
Please note medical history, diseases and important medical information.
Examples: Chicken Pox, Diabetes, Bleeding Disorders, etc.
Your answer
FOOD ALLERGIES
MEDICATION ALLERGIES
DIETARY NEEDS
Are there special dietary needs for this student?
If there are allergies to specific foods, please go back to the health history section.
Please check each of the following medications that MAY be administered to your student.
If needed, while on a PCW event/trip or participating in an event at the church.
Medical Insurance Information
Insurance Company Name
Your answer
Member ID
Your answer
Group/Policy Number
Your answer
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 2017/2018. 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 2017/2018 Registration Form. Also, you authorize medical care for your son/daughter in the event of an illness, injury and/or emergency.

Parent/Guardian Initials *
Your answer
Submit
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