2020 - 2021 Children and Youth Wednesday Night Registration Form

How many children are you registering? *

Child's Name *

First Name Last Name Child Prefers to be called

Child's Birth Date *

Month Day Year

Gender *

Male Female

Grading Going Into *

Does the child attend Sunday school anywhere? *

Yes No

Where?

Medical or other information we may need to know about the child (including food allergies). If none type none. *

Child's Name *

First Name Last Name Child Prefers to be called

Child's Birth Date *

Month Day Year

Gender *

Male Female

Grading Going Into *

Does the child attend Sunday school anywhere? *

Yes No

Where?

Medical or other information we may need to know about the child (including food allergies). If none type none. *

Child's Name *

First Name Last Name Child Prefers to be called

Child's Birth Date *

Month Day Year

Gender *

Male Female

Grading Going Into *

Does the child attend Sunday school anywhere? *

Yes No

Where?

Medical or other information we may need to know about the child (including food allergies). If none type none. *

Child's Name *

First Name Last Name Child Prefers to be called

Child's Birth Date *

Month Day Year

Gender *

Male Female

Grading Going Into *

Does the child attend Sunday school anywhere? *

Yes No

Where?

Medical or other information we may need to know about the child (including food allergies). If none type none. *

Parent/Legal Guardian Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Parent/Legal Guardian Name

First Name Last Name

Phone Number

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Names of Persons to which the child (children) may be released to each night after programs (Please provide at least two) *

First Name Last Name

Full Name *

First Name Last Name

Full Name

First Name Last Name

Full Name

First Name Last Name

Are there any persons to which the child (children) may NOT be released to? *

Yes No

Who may you child (children) NOT be released to?

Emergency Contact 1 (other than parent/guardian listed above) *

First Name Last Name

Relationship *

Emergency Contact 1 Phone Number *

Area Code Phone Number

Emergency Contact 2 (other than parent/guardian listed above) *

First Name Last Name

Relationship *

Emergency Contact 2 Phone Number *

Area Code Phone Number

Does any child/youth need transportation? *

Yes No

If yes, what is the pickup and drop off address?

By clicking the box below, I hereby grant West Salem Trinity United Methodist Church or its affiliates the permission to use my child’s/children’s likeness in photographs, video, and other media in any and all of its publications, including bulletin boards and website entries. I hereby Give Permission for photographs and/or video in which my child/youth appears in to be used by the church in printed and/or electronic media, including the church's website. I waive any right to royalties or other compensation arising or related to the use of the photographs or videos. *

I Agree

By clicking the box below, I hereby grant West Salem Trinity United Methodist Church and leaders/volunteers to take whatever steps they deem necessary to ensure the well-being of my child/children should a medical emergency occur during a meeting/activity. Every attempt will be made to contact the care-giver and/or emergency contacts provided. My child/children are in good physical health and do not have any conditions or disabilities which may be aggravated except as noted on this form. In the event that I cannot be reached in an emergency, I hereby authorize the physician selected by West Salem Trinity United Methodist Church to hospitalize, secure proper treatment for, and order injections, anesthesia and surgery for my child/children named above. *

I Agree

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. As a result, federal, state, and local governments and agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. We are doing everything we can to be compliant with all regulations and ensure your safety. We have put in place preventative measures to reduce the spread of COVID-19, but we cannot guarantee that you or family members will not become infected with COVID-19.

By clicking the box below you agree to the following:

“On behalf of yourself and your children, you hereby release, convenant not to sue, discharge, and hold harmless West Salem Trinity United Methodist Church, its employees, agents, and representatives, of and from all liabilities, claims, actions, damages, cost or expenses of any kind arising out of or relating to you participation in our programs, services, or activities. You understand and agree that this release includes any claims based on actions, omissions, or negligence of this organization, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during or after participation in any such program, service, or activity.“

*

I Agree

By clicking the box below, "

“I hereby grant permission for my child/children to participate in activities arranged by West Salem Trinity United Methodist Church. I recognize the importance of the commitment that he/she makes and that their participation as a part of a larger community calls for responsible behavior. Therefore, I agree that if this child engages in behavior which, in the judgment of the adult leaders, is not in the best interest of the trip or event, my child or any member of the group may, therefore, be sent home. I will assume full legal and financial responsibilities for such a return trip.”

“I hereby release from any liability West Salem Trinity United Methodist Church and all of its personnel, employees, adult leaders and representatives from any claims for unintended or unexpected accidents which might occur during participation in youth group events or traveling to or from said events. In granting this permission and release, I specifically recognize that my child may from time to time be transported to events by private vehicles operated by advisors or volunteers not as agents, employees or representatives. In such regard, I specifically release and will hold harmless West Salem Trinity United Methodist Church, their officers, employees, agents and representatives from any and all liability which may arise as a result of such transportation whether or not organized by West Salem Trinity United Methodist Church.”

*

I Agree

2020 - 2021 Children and Youth Registration

Child Information

First Child

Second Child

Third Child

Fourth Child

Child Release Information

Transportation

Media Release

Medical Release

Covid-19 Release

General Release