SBC Youth Registration
Grades 6 to 12
Sign in to Google to save your progress. Learn more
Email *
Youth's First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Parent/Guardian First and Last Name (primary caregiver) *
Home Address *
Email *
Home Phone
Cell Phone *
Work Phone *
Parent/Guardian #2 First and Last Name (if applicable)
Home Address
Email
Home Phone
Cell Phone
Work Phone
Medical Matters: Fill in all information, put N/A if applicable.
Medicare Number *
Allergies *
Family Doctor *
Family Doctor Phone number *
Any special medical conditions (i.e. asthma) and medications youth requires? *
Can we give your youth non-prescription medication (ie Tylenol, Advil, cold medications, etc) if deemed appropriate? *
In the event of an emergency, if we are unable to reach any of the above persons, please contact:
Name and relationship of contact *
Phone number *
I agree on behalf of myself, my youth named herein to participate in this ministry of Salisbury Baptist Church, its leaders, volunteers/chaperones, its employees, or representatives associated with the event, from any claim arising from or in connection with my youth attending the event or in connection with any illness, injury or medical treatment therewith. And I agree for my youth to receive medical attention (if required) while with the church, its leaders, its employees, chaperones, or representatives associated with the event provided by Medicare. And if any costs are not covered by Medicare, I am responsible for the fees and expenses which may incur in any action brought against my youth as a result of such injury or damage.
Emergency Medical Treatment: In the event of an emergency, I hereby give permission for Salisbury Baptist Church and its representatives to transport my youth to a hospital if emergency medical or surgical treatment is necessary. SBC will notify the parent/guardian/emergency contact if such is the case.
 *
Required
I give permission for my youth's photograph to be taken and used by Salisbury Baptist Church on their website and/or social media platforms. 
 *
Please note that this form is good for every special event either hosted by the church or offsite for the current (2023-2024) school year unless otherwise indicated. Items like medications, a brief description of the activity, and any recent medical conditions/diseases (ie: chicken pox, measles, etc) must be written on each event's permission form.
I agree that all the information above is correct and I understand that this form will be held confidential and used only for SBC Youth Group purposes. As the parent/legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("youth"). Please type your name and date below, this will be taken as your signature. *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms