Youth Ministry Registration

"*" indicates required fields

Student Name*

First Middle Last

Student Cell Number

Student School*

Student Birth Date*

Student Age*

Please enter a number less than or equal to 18.

Student Grade*

Household Mailing Address*

Street Address Address Line 2 City State ZIP Code

Parent 1 Name*

First Last

Parent 1 E-mail

Parent 1 Cell Number*

Parent 2 Name

First Last

Parent 2 E-mail

Parent 2 Cell Number

Who Should Receive Youth Text Alerts?*

Parent 1

Parent 2

Student

Authorized people to pick up my student (must be 18 years of age or older):*

Please add one per line, click + to add additional line

Is there any custodial information that we should be aware of? If so, please list below:

Are there any allergies that we need to be aware of?

Are there any special considerations that we need to be aware of?

Is there anything else that we should be aware of about your child?

Consent*

I agree to the below statement.

I authorize photos of my child to be taken during Youth Ministry activities for use in Pfrimmer’s Chapel marketing materials.

Consent*

I agree to the below statement.

As a participant in the Youth Ministry of Pfrimmer’s Chapel United Methodist Church, we (I), being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 18 years of age or older) do hereby release, forever discharge and agree to hold harmless Pfrimmer’s Chapel United Methodist Church as well as its employees and volunteers thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described activity. Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. By selecting “I agree” and signing electronically below, I hereby agree to hold harmless and indemnify said organization, its directors, employees and agents, for any liability sustained by said organization as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. We (I) are the parents(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him or her to participate fully in our Youth Ministry, and the activities done there.

Parent Signature*

By signing below, I certify all information is true and correct to the best of my knowledge.

Parent Signature Date*