Youth Groups

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Youth Groups

1st and 3rd Fridays Monthly

Email *

Last Name *

First Name *

Birthday (Day/Month/Year) *

YYYY

Allergies: *

Any physical or behavioural special needs? *

Phone Number *

Primary Contact/Parent/Guardian (Last Name & First Name) *

Primary Contact/Parent/Guardian (Phone Number: Home & Cell) *

Primary Contact/Parent/Guardian (Relationship to Child) *

Primary Contact/Parent/Guardian (Address - including City & Postal Code) *

Emergency Contact Name & Phone Number *

Grade starting in September *

Parents/Guardians please read the following statement and check the box to indicate your agreement.

I acknowledge and understand that all information collected is for the sole purpose of the First Presbyterian Church and will not be shared by other parties.

Required

Parents/Guardians please read the following statement and check the box to indicate your agreement.

I acknowledge and understand that by entering the premises of the First Presbyterian Church or engaging in Church sponsored activities outside of the Church, consent to my child(ren)'s voice and likeness being videotaped and used without compensation for use in any format or media channel ow known, or hereafter devised as the First Presbyterian Church sees fit. You further release the First Presbyterian Church and its assignees, licensees, directors, officers, employees, agents and contractors from any liability on account of such usage.

Required

Parents/Guardians please read the following statement and check the box to indicate your agreement.

I acknowledge and understand that in the case of emergency that every effort will be made to make contact parents or guardians immediately. However, if parents or guardians cannot be reached, I hereby grant First Presbyterian Church to act on my behalf in seeking medical attention by contacting 911.

Required

If you have any questions please contact the church office: firstchurch@rogers.com. Date submitted: *

YYYY

Send me a copy of my responses.

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