Youth Information form

Youth Information form

Colonial Hills UMC youth ministry activities, which may include overnights and events that take place away from church. Permission includes transportation by adult staff and volunteers
STUDENT INFORMATION
Youth Name*

First NameLast Name
Age*
Gender *
Date of Birth*

MonthDayYear
Date
Student Phone Number (If applicable) *
Please enter a valid phone number.
Student Email Address (If applicable) *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School*
Grade Level for current school year*
Insurance Provider Name*
Medical Insurance #*
Date of last tetanus short*

MonthDayYear
Date
Does this youth have any allergies?*
Does this youth have any medical conditions that we should be aware of?*
Mother's information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address *
Father's information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address *
PARENT OR LEGAL GUARDIAN PLEASE READ AND SIGN
My child has permission to participate in CHUMC Youth activitiesI release Colonial Hills United Methodist Church, staff, and volunteers from liability if my child gets hurtIn case of medical emergency, I give permission to the medical personnel and facilities selected by adult supervisory staff and volunteers to provide treatment deemed necessary for my childI give my permission for my child’s/children’s image to be printed and/or posted on awebsite or social network page associated with Colonial Hills United Methodist Church
Parent/Guardian Signature

Clear
Date Signed*

MonthDayYear
Date
YOUTH PLEASE READ AND SIGN

Covenant of CHUMC youth
I will be kind to others in word and action. I will be respectful of leaders, including completeing tasks that I am assigned. I will inform adult leaders when I am leaving. I will respect any hosts, including CHUMC, camps, and other facilities. (This includes cleaning up after myself.) I will be a good representative of our church. I will respect others' space and preperty. I will not have any alcohol, tobacco, vapes, juuls, esco bars, drugs, weapons (including knives), lighters, matches, or pornographic material at any youth related event. I will keep physical displays of affection to a minimum. I realize there are consequences for my actions. (This could include being sent home.) I will seek to build my faith of those around me.

I will abide by the Covenant of CHUMC Youth.
Youth Signature

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Youth Information form

STUDENT INFORMATION

Mother's information

Father's information

PARENT OR LEGAL GUARDIAN PLEASE READ AND SIGN

YOUTH PLEASE READ AND SIGN