United Christian Church 2022-2023 Youth Release Form
This form is required for your youth to participate in any online or in person activities.  
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Youth #1 First Name *
Youth #1 Middle Name
Youth #1 Last Name *
Youth #1 DOB *
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Youth #1 Current Grade Level and School *
Youth #1 email address (if none, simply indicate "none") *
Youth #1 cell phone number (if none, simply indicate "none") *
Youth #1 T-Shirt Size *
Youth #1 has received their Covid Vaccinations *
Youth #2 First Name
Youth #2 Middle Name
Youth #2 Last Name
Youth #2 DOB
MM
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DD
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YYYY
Youth #2 Current Grade Level and School
Youth #2 email address (if none, simply indicate "none")
Youth #2 cell phone number (if none, simply indicate "none")
Youth #2 T-Shirt Size
Youth #2 has received their Covid Vaccinations
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Youth #3 First Name
Youth #3 Middle Name
Youth #3 Last Name
Youth #3 DOB
MM
/
DD
/
YYYY
Youth #3 Current Grade Level and School
Youth #3 T-Shirt Size
Youth #3 email address (if none, simply indicate "none")
Youth #3 cell phone number (if none, simply indicate "none")
Youth #3 has received their Covid Vaccinations
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Youth #4 First Name
Youth #4 Middle Name
Youth #4 Last Name
Youth #4 DOB
MM
/
DD
/
YYYY
Youth #4 Current Grade Level and School
Youth #4 T-Shirt Size
Youth #4 email address (if none, simply indicate "none")
Youth #4 cell phone number (if none, simply indicate "none")
Youth #4 has received their Covid Vaccinations
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May we use your youth's email address to contact them about youth events? *
May we use your youth's cell phone to contact them about youth events? *
Parent's name(s) *
Parent's email address(es) - Please provide the email you use the most *
May we use your email(s) to contact you about youth events? *
Parent's cell phone number(s).  If entering multiple numbers, please indicate who each belongs to *
Name of person, other than parent listed above, to be an Emergency Contact *
Emergency Contact relation to youth *
Emergency Contact Phone Number *
Insurance Provider *
Insurance Group # *
Insurance contact number (usually on the back of insurance card) *
Doctor and Doctor's office phone number *
Youth #1 - Are there any health concerns, food allergies, or medications that we should know about? *
Youth #1 - Is there anything we can do to make their youth group experience more comfortable? *
Youth #2 - Are there any health concerns, food allergies, or medications that we should know about?
Youth #2 - Is there anything we can do to make their youth group experience more comfortable?
Youth #3 - Are there any health concerns, food allergies, or medications that we should know about?
Youth #3 - Is there anything we can do to make their youth group experience more comfortable?
Youth #4 - Are there any health concerns, food allergies, or medications that we should know about?
Youth #4 - Is there anything we can do to make their youth group experience more comfortable?
I willingly allow my child(ren) to participate in events/programs organized by United Christian Church – Youth Group.  In the event that he/she/they is/are injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate and active for any care my child may require.     *
I give my permission for United Christian Church to use my child’s picture on their website, social media sites, and for media releases (web & print) in which to advertise a church event. *
I give my permission for United Christian Church to use my child’s picture ONLY on the private Youth Group Facebook page or private In House Facebook page (these pictures are not posted publicly, they are only seen by members of our church). *
We love to have youth participating in all aspects of life here at United Christian Church.  In what areas might your youth be willing to contribute?
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