PLUGGED-IN Youth Registration

PLUGGED-IN Youth Registration
Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Unionville Alliance Church. Any medical information collected here serves to authorize Unionville Alliance Church, and its Staff and Volunteers, to obtain medical assistance in emergencies. This form should be completed annually by the Parent / Care Giver.
Child 1
Name *

First Name Last Name
Gender *

Male Female
Date of Birth

Month Day Year
Date
Grade *
School Name
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Allergies/Medical Concerns (if Not Applicable, please put N/A) *
Is your child bringing any medication with them? *

Yes No
If yes, please list
Does your child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of? *

Yes No
If yes, please explain

Parent/Guardian 1 (Emergency Contact)
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Please sign me up for email updates from Youth Ministries *

Yes No
Parent/Guardian 2
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Please sign me up for email updates from Youth Ministries

Yes No

Photos/ Videos

Unionville Alliance Church desires to promote programming with photos and videos captured during gatherings and events.
Photo/Video/Electronic Images

I give Unionville Alliance Church permission to use photographs, video or electronic images of my Child(ren). I authorize Unionville Alliance Church to copyright, use and publish the media for any lawful purpose to highlight or promote Unionville Alliance Church. By checking this box and signing I indicate that I have read and understood the above release.
Video Meeting Recordings

I give Unionville Alliance Church permission to use recorded video of my Child(ren) from video meetings (i.e. zoom). I authorize Unionville Alliance Church to copyright, use and publish the media for any lawful purpose to highlight or promote Unionville Alliance Church. By checking this box and signing I indicate that I have read and understood the above release.
Medical Consent/Release

I/we, the Parents or guardians named below, authorize Unionville Alliance Church Ministry Personnel to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above, if I/we are unavailable. I/we, named below, undertake and agree to indemnify and hold harmless Ministry Personnel, Unionville Alliance Church, and its Leaders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Unionville Alliance Church, as well as of any medical treatment authorized by the supervising individuals representing Unionville Alliance Church. This consent and authorization is effective only when participating in or traveling to events sponsored by Unionville Alliance Church.
Purposes and Extent

Unionville Alliance Church is collecting and retaining this personal information for the purpose of enrolling your Child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your Child, and to inform you of program updates and upcoming opportunities at Unionville Alliance Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Unionville Alliance Church to limit the information collected, or to view your Child’s information, please contact us.
I have read, understood and agree with the above.
Parent/Guardian 1 (Emergency Contact) *

Clear
Date *

Month Day Year
Date
Parent/Guardian 2

Clear
Date

Month Day Year
Date
Should be Empty:

PLUGGED-IN Youth Registration

Child 1

Child 2

Child 3

Parent/Guardian 1 (Emergency Contact)

Parent/Guardian 2

Photos/ Videos

Medical Consent/Release

Purposes and Extent

I have read, understood and agree with the above.