FUMC Wiggins Youth Registration Form

YOUTH Registration 2022-2023

First United Methodist Church @ the bottom of Pine Hill Wiggins, MS
Youth information
Student's Name*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Grade enrolled in for the 21-22 school year*
ELECTRONIC COMMUNICATION CONSENT Please use the text below to type your name and YES or NO, if you give permission for an adult leader of FUMC to request access, friend, text, contact via social media, or use any other form of online, phone/video communication with you and your child.
AgreeDisagree
Electronic Signature for approval for Electronic communication

Clear
Parent Information
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Phone Number*

Area CodePhone Number
Parent/Legal Guardian Email*
example@example.com
Address*

Street Address

Street Line 2

CityState / Province

Postal / Zip Code
Parent Name

First NameLast Name
Phone Number

Area CodePhone Number
Release Information
Who may you child NOT be released to?
If there are legal papers, please note
Names of Persons to whom the child may be released to *

First NameLast Name
Full Name*

First NameLast Name
Full Name

First NameLast Name
Full Name

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

First NameLast Name
Area CodePhone Number
Emergency Contact 2 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 2 Phone Number*

Area CodePhone Number
Media, Medical and Transportation Release
AgreeDisagree
Electronic Signature for approval of Usage of Digital Likeness

Clear
AgreeDisagree
Doctor's Name *
Doctor's phone # *

Area CodePhone Number
Birth Date *

MonthDayYear
Medical Insurance Provider*
Medical Group ID# *
IF ANY OF THE INFORMATION GIVEN ABOVE CHANGES, I AGREE TO NOTIFY THE OFFICE IMMEDIATELY.
The Undersigned hereby gives permission for the child named below (the “CHILD”) to participate in activities of the FUMC, including but not limited to recreational activities, field trips and travel to events held outside Wiggins FUMC. Further, in the event that medical treatment for the CHILD is required during the course of said activities, I hereby give my authorization to any adult who then has care and control of the CHILD to consent to medical treatment of the CHILD.I understand that an effort will be made to contact me concerning such medical treatment as soon as practicable and that I will be financially responsible for any and all medical treatment provided pursuant to this consent.I hereby affirm that I am the parent and/or managing conservator or guardian of the CHILD and have full legal consent, shall remain in full legal authority to consent to his or her medical treatment. This consent shall remain in full legal authority to consent to his or her medical treatment. This consent shall remain in full force until revoked in writing by me and delivered to the offices or a legal representative of FUMC. I hereby authorize any health care provider to accept a photocopy of this form as effective. Further, by this document I hereby give my consent for the release of medical records and/or history of the CHILD to any health care provider supplying services pursuant to the consent of medical treatment.
Electronic Signature for approval of Travel and Medical Release

Clear
Date

MonthDayYear
Date
Electronic Signature for approval of Travel and Medical Release
Should be Empty:

YOUTH Registration 2022-2023

Youth information

Parent Information

Release Information

Media, Medical and Transportation Release