Wyalusing Presbyterian Church

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Sunday School 2021-2022 Registration

Email *

Liability Release #1: Please thoroughly read and check your agreement. Checking a box will signify your understanding and compliance of the statement. *

With full knowledge of the risks involved, I hereby release, waive, discharge the Wyalusing Presbyterian Church, its session, independent contractors, affiliates, employees, volunteers, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by anyone attending Sunday School related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

I do not agree.

Liability Release #2: Please thoroughly read and check your agreement. Checking a box will signify your understanding and compliance of the statement. *

I agree to indemnify, defend, and hold harmless the Wyalusing Presbyterian Church from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

I do not agree.

Liability Release #3: Please thoroughly read and check your agreement. Checking a box will signify your understanding and compliance of the statement. *

I will not send anyone from my household if anyone has experienced symptoms of fever over 100.2, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease.

I do not agree.

Name of Child #1 *

Date of Birth for Child #1 *

YYYY

Age Group for Child #1 *

Child #1 Medical Considerations and/or Allergies *

Name of Child #2

Date of Birth for Child #2

YYYY

Age Group for Child #2

Child #2 Medical Considerations and/or Allergies

Name of Child #3

Date of Birth for Child #3

YYYY

Age Group for Child #3

Child #3 Medical Considerations and/or Allergies

Mailing Address *

Contact Number for Parent/Guardian *

Emergency Contact (name and number must be different than above name and number) *

Adult(s) that Child/ren May be Released To (other than those already listed)

Media Release (For pictures and videos ONLY) *

You may use photos and/or video taken of my child/ren for advertising, newspaper publications, website photos, and social media.

You may NOT use photos and/or video taken of my child/ren for advertising, newspaper publications, website photos, and social media.

Media Release (For LIVE STREAMING and/or LIVE BROADCASTING) *

I grant Wyalusing Presbyterian Church permission to live stream and/or broadcast my child/rens participation in Sunday School events and/or church services and/or events through various platforms.

I do NOT grant Wyalusing Presbyterian Church permission to live stream and/or broadcast my child/rens participation in Sunday School events and/or church services and/or events through various platforms.

Volunteer *

I am willing to turn in my up-to-date clearances and would be available to assist in Sunday School tasks

I am looking for further information on everything Wyalusing Presbyterian Church has to offer.... please contact me

I am not able to help.

Please type your name to serve as a digital signature: *

A copy of your responses will be emailed to the address you provided.

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