Youth Registration Form 2024-2025

Youth Group 2024-2025

For Youth Group participants 6th-12th grade. PreK-5th grade, please use other form.
Church Affiliation?

ImmanuelFaith CongFirst Church MiddletownNone/other
Child #1

First NameLast Name
Birth Date

MonthDayYear
Gender
Grade if applicable
School
Youth Cell

Area CodePhone Number
Child #2

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Grade if applicable
School
Youth Cell

Area CodePhone Number
Child #3

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Grade if applicable
School
Youth Cell

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Parent Name #1

First NameLast Name
Contact Email
example@example.com
Preferred Contact Phone

Area CodePhone Number
Parent Name #2

First NameLast Name
Contact email
Preferred Phone Contact

Area CodePhone Number
Special needs/accommodations?
Medical Info & Permission to Treat
Please use the space below to detail and explain any medical condition about which our leaders should be aware. Please attach any records or other details if necessary. Also, please note any medications that your child must have administered during the time away. Medications must be provided directly to group leader in the original container with explicit instructions regarding dispensation.
Physician's Name and Phone Number
Allergies and/or dietary restrictions
Insurance name and insurance phone number
Group #/Member ID#
Primary Holder and Date of Birth
Primary Holder Employer and work phone
Emergency Contact (to be called if parents are not able to be reached) Name & number
I give permission for my child to participate in all YG activities during the 2024-2025 year including but not limited to: Sunday afternoon/evenings, team activities, special events and other activities where transportation must be provided by private car, van, train, plane or bus. I hereby release and discharge Immanuel Congregational Church, UCC together with any of its successors, assigns, employees, or volunteers, from any and all losses, damages, or claims I have or may have in the future arising directly or indirectly, in any way from my child’s participation in any YG activity. I hereby agree to indemnify and hold harmless Immanuel Congregational Church and any of its successors, assigns, employees, or volunteers from any claims made against any or all of them arising, directly or indirectly, in any way out of my child’s participation in any YG activity. I hereby authorize Immanuel Congregational Church, UCC or any of its employees or volunteers and any physicians, nurses, EMT personnel or hospital or emergency facility to provide or arrange for any medical services or treatment to my child for injuries or illnesses which may arise during the course of any YG activity.
Parent/Guardian Signature

Clear
Photo/Video Release
I give permission for my child’s photo/video to be taken by Church staff or volunteers during activities, with the understanding that pictures might be used in Immanuel Congregational Church publications. Note that Immanuel does not control the taking of photographs by other participants.

YesNo
Youth Ministry Behavioral & Cell Policy

Parent/Legal Guardian and Youth Group Member –Please read this covenant and sign.
Cell Phone Policy

Youth members will be responsible for their own cell phones and cell phone use in accordance with this policy.

• Cell phones are to be used at designated times to contact parents/guardians.
• Cell phones can be used to contact youth leaders as necessary during all youth events when out of line of sight.
• Cell phones cannot be used during transportation to/from youth events, trips, or youth meetings.

When cell phones are not used in accordance with the above policy, the following action will be taken by the adult youth leaders.

• 1st offense: verbal warning
• 2nd offense: cell phone will be powered down and parent/guardian will be made aware that they can reach their child through one of the adult group leaders.
Behavioral Expectations

Youth cannot participate in the group unless they have signed this Behavioral Covenant. Our Youth Ministry mission includes a commitment to nurture and sustain a community of love, covenant, and participation. We seek to be a community in which all of our youth are unconditionally loved and accepted as they are, share covenantal commitments and participate in something larger than themselves: the great adventure of loving and serving in God’s name. If we are to fulfill this mission, each of us must commit ourselves to a covenant of mutual care, love and respect. This Youth Ministry Behavioral Covenant sets forth our commitment. Youth agree and covenant to adhere to all policies of the group in all activities, including but not limited to all online or in person meetings, programs, gatherings, retreats, activities and mission trips. This Youth Ministry Behavioral Covenant includes, but is not limited to the following covenantal agreements:

Youth agree and covenant not to possess or use tobacco products of any kind.

Youth agree and covenant not to possess or use alcohol or other drugs of any kind not prescribed for that YG member by a physician.

Youth agree and covenant not to engage in any behavior that the YG or trip location staff deems a threat to an YG member’s personal safety or to the safety of any other YG member, YG group or trip location staff member, or other citizen or guest of the trip location.

Youth agree and covenant not to misappropriate, steal or damage any property belonging to a fellow YG Member, an YG staff member, or any organization or facility that partners with or welcomes the YG group to their facility or program.

Youth agree and covenant not to engage in sexual activity or inappropriate sexual behavior during any related event or activity.

I understand that the Youth Ministry maintains a Zero Tolerance standard for violations of the Behavioral Covenant. Should my child violate any of the rules listed under the Youth Ministry Behavioral Covenant, I expect to be asked to immediately travel to the location of the activity to withdraw my child from the group and to accompany my child home. If requested, I will willingly comply with such request. I understand that any and all inconveniences, hardships, and expenses incurred as a result of such action requested by the group leaders are to be born directly and entirely by me. Neither the Youth Ministry nor Immanuel Congregational Church, nor the trip location will bear any responsibility for any expenses.

My child and I have read and reviewed the Youth Ministry Behavioral Covenant. My child and I acknowledge our understanding of the Covenant and pledge to adhere to it.
Adult Signature

Clear
Youth Signature

Clear
Youth Signature

Clear
Youth Signature

Clear
Should be Empty:

Youth Group 2024-2025

Medical Info & Permission to Treat

Photo/Video Release

Youth Ministry Behavioral & Cell Policy