Youth Group Registration

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Email *

Name of Primary Contact Parent/Guardian
*

Relationship to Youth *

Email *

Phone Number *

Address, City, Postal Code *

Name of Secondary Contact Parent/Guardian

Relationship to Youth

Phone Number

Address, City, Postal Code

Name of Youth #1 *

Date of Birth (DD/MM/YYYY) *

Grade Starting in September *

Gender *

Male

Female

Address *

Same as Primary Contact

Other:

Any interests (Sports, Music, etc.)

Allergies

Any physical or behavioral special needs (seizures, autism, ADHD, etc.)

Name of Youth #2

Date of Birth (DD/MM/YYYY)

Grade Starting in September

Clear selection

Gender

Male

Female

Clear selection

Address

Same as Primary Contact

Other:

Clear selection

Any interests (Sports, Music, etc.)

Allergies

Any physical or behavioral special needs (seizures, autism, ADHD, etc.)

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

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

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