PYF Registration & Medical Release Form 2021-2022
Please complete the form below to register your student for the 2021/2022 school year.  If you have more than one child you will need to complete the form for each child.  If you have any questions, feel free to contact the church at 704.664.5275.
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Email *
Participant's Name:  Last, First *
Participant's School: *
Grade Level 2021-2022 School Year *
Birthdate *
MM
/
DD
/
YYYY
Gender *
Home Address:  Ex:  123 Church St, Mooresville, NC, 28115 *
Student's Cell Phone: *
Do you wish to receive texts at this number? *
Student's Email: *
Student's ICE (in case of emergency) Phone Number: *
Briefly describe any special health conditions or allergies (including food allergies) or n/a if not applicable. *
Medications (list name, dosage, prescribing physician) or n/a if not applicable. *
#1 Parent/Guardian Name:  Last, First *
Home Phone: *
Mobile Phone: *
Parent/Guardian Email *
#2. Parent/Guardian Name: *
Home Phone: *
Mobile Phone: *
Email Address: *
Program Consent:  I, the undersigned, hereby consent for my child to participate in the First Presbyterian Church of Mooresville, NC's Youth Program (PYF).  Type your full name below. *
Medical Consent:  In the event of the above named participant becomes ill or sustains an injury during a FPC youth program at the church or on an authorized trip, I, the undersigned, hereby consent to have my child treated by an Emergency Medical Technician and/or licensed physician in the event of an accident or medical emergency.  I understand that this consent will apply to all emergency situations present and future and that it remains in effect until written revocation is received. Type your full name below.   *
Liability Consent:  I, the undersigned, hereby agree not to hold First Presbyterian Church of Mooresville, NC, or its leaders, employees, or volunteer staff liable for any damages, losses, illnesses, diseases or injuries while participating in one or more of the registered youth programs.  Type your full name below. *
Transportation Consent:  I, the undersigned, hereby consent for my child to be transported to and from authorized FYC youth activities in any vehicle driven by an approved adult youth worker from FPC or licensed charter bus driver.  Type your full name below. *
Media Consent:  I, the undersigned, hereby consent that the FPC has the right to photograph, videotape, or make digital recordings of my child and to use these media from here on forward in the FPC publications (for example, bulletins, flyers, webpages, Facebook, etc.). This consent remains in force until written revocation is received. For your child's protection, his or her name will not be made known.  Type your full name below. *
PYF POLICIES
PYF Participant Policy Agreement: I have read the behavior statement and policies above and I agree to be responsible for my behavior in accordance with the guidelines stated there. My parents and I understand that violation of the guidelines may result in my being sent home at the expense of my family/guardians.  Type full name below.             *
Parent/Guardian:  I have agreed to submit this application by electronic means.  By typing my name below, I am electronically signing my application. *
A copy of your responses will be emailed to the address you provided.
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