CPC Youth 24-25

Colbert Presbyterian Church Youth Registration and Permission Slip

2024-2025 Youth Programs
Student Information
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Grade*
School*
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student Phone Number

Area CodePhone Number
Student E-mail
Allergies, concerns, or comments
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian E-mail*
example@example.com
Parent/Guardian Phone Number*

Area CodePhone Number
Parent/Guardian Name

First NameLast Name
Parent/Guardian E-mail
example@example.com
Parent/Guardian Phone Number

Area CodePhone Number
Emergency Contact Information
Emergency Contact Name*

First NameLast NameRelation to Student
Emergency Contact Phone Number*

Area CodePhone Number
Permission
My student has my permission as her/his parent or legal guardian to participate in any and all events and activities sponsored by Colbert Presbyterian Church during the 2024/2025 school year.

I acknowledge that by participating in church sponsored events, my child may be involved in activities both on and off church property, during both day and evening hours. I further acknowledge that by participating in church-sponsored events, my child may be involved in recreation and sporting activities.

In recognition of these risks and realities in consideration of my student being offered the opportunity to participate in and benefit from these church-sponsored events, I agree on behalf of myself and my student to release, waive and disclaim any and all liabilities of or claims against Colbert Presbyterian Church.

I further idemnify Colbert Presbyterian Church for any and all damage or injury my child may cause to others as a result of his/her participation in the church-sponsored events. I further understand that it is my responsibility to keep current the information contained on all record held in the church office including, but not limited to, my address, phone, emergency contact and insurance information.
Video/Photo Release
Unless I have indicated otherwise below, I understand that pictures, video, recordings, and/or audio recordings of my child may be displayed in brochures, newsletters, video productions and/or other electronic media designed and distributed to inform the congregation and/or general public of programs and events taking place in the church. I understand that my child will not be identified by name without my express written permission.
I do NOT want any video or audio or pictures of my student displayed on the church property or in brochures or newsletters, video productions or other electronic media designed to inform the congregation and/or general public of programs and events taking place in the church.
Health
In the event my student requires medical attention and I cannot be reached immediately, I give permission for Colbert Presbyterian Church staff, volunteers, teachers, or youth/children directors to authorize medical attention.
Electronic Signature of Parent/Guardian
Date
Should be Empty:

Colbert Presbyterian Church Youth Registration and Permission Slip

Student Information

Parent/Guardian Information

Emergency Contact Information

Permission

Video/Photo Release

Health