Children and Youth Release and Registration 2025

Children and Youth Ministry Registration Form for 2025/2026 Program Year

Please fill out the form carefully for each child/youth
Student Name*

First NameMiddle NameLast Name
Parent(s) name*

First NameLast Name
Parent(s) name*

First NameLast Name
Birth Date*

MonthDayYear
Entering Grade (Fall 2025)
What school will your child attend?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent E-mail *
example@example.com
Parent Mobile Number*
Phone Number
Ministry Registration
In order to properly prepare for your child's participation in Children's Ministry, please fill out the following registration questions.
My Child/Youth will attend Sunday School | 10:20-11:05:

YesNoUnsure
If unsure, can we check again prior to the Fall program? (elaborate if you'd like)
My Child/Youth will attend the Wednesday Night Program | 6:00-7:15:

YesNoUnsure
If unsure, can we check again prior to the Fall program? (elaborate if you'd like)

Health and Medication

Health and medical information needs to be made known to Program leadership. All information will be held in confidence. All medications(including “over-the-counter” meds) must be listed.
Does Participant have any allergies?*

YesNo
Please explain in detail:
Does Participant have any physical restrictions?*

YesNo
Please explain in detail:
Are there any other medical conditions we need to be made aware of?*

YesNo
Please explain in detail:
Medications

This includes any and all emergency medications such as epi-pens.
Medicine: blanks Dose blank     Condition:   blanks
Medicine: blanks Dose blanks     Condition:   blanks
Medicine: blanks Dose blanks     Condition:   blanks
Additional Notes:
Emergency and Liability Release
The health information recorded on this form is correct as far as I know, and the minor child named and described above has permission to engage in all Christ Church Anglican activities except as noted. I have familiarized myself with the Program and events and understand all activities are completely voluntary. I recognize the inherent risk of injury in activities including, but not limited to, outdoor games and other activities listed on the program schedule.

While Christ Church Anglican has safety protocols in place to manage allergen related issues, I understand that a minor child with specific allergies or intolerances has a role and responsibility in the avoidance of the known allergen. I agree to educate my child, who has allergies or intolerances, to ask questions, read labels, and avoid the substance in question when in doubt.

I understand that Christ Church Anglican has taken proper safety measures to aid the safety of all participants. However, I recognize that Christ Church Anglican cannot ensure or guarantee the participants, equipment, grounds, and/or activities will be free of accident or injuries. I am aware of, and have instructed my child, in the importance of knowing and abiding by the program rules and regulations, and I voluntarily agree that Christ Church Anglican, its agents, officers, employees, and volunteers will not be liable for any injury, death, damage and/or loss to my child, and/or anyone claiming on my child's behalf, and I further agree to hold harmless, indemnify and defend Christ Church Anglican, its officers, staff, agents, employees, and volunteers for and from any and all liability, claims, losses, injuries, expenses, fees and/or damages arising out of any injury, illness or death to my child during my child's attendance at Christ Church Anglican programs.

In the event I cannot be reached immediately, I hereby grant permission for my minor child to receive basic first aid and emergency treatment for any illness or injury which requires emergency treatment, including permission to secure emergency transportation for my child to an appropriate medical facility. I understand that the information on this form may be released in an emergency situation on a need to know basis to aid in the treatment and care of my child.
Opt in or out [Choose only one]

OPT-IN Christ Church Anglican activities may have a photographer or videographer present. Photos or video from CCA activities may later be included in some of CCA’s written materials, CCA’s social media postings, and/or CCA’s website.I acknowledge and understand that CCA materials are subject to the following protections: (1) CCA’s use will be for church-related purposes only; and(2) CCA will not use any image that individually identifies a child by name or otherwise. CCA will not release any personally identifiable information without prior written consent from you as parent or guardian.OPT-OUT (Social Media and Website): I do not consent to photos or videos of my child being used in CCA’s social media posts or on the CCA website. This does not apply to livestreamed services, which may include incidental footage of participants and are not subject to opt-out. Parents/guardians may revoke photo/video consent for future use by submitting a written request to the CCA office.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Children and Youth Ministry Registration Form for 2025/2026 Program Year

Ministry Registration

Health and Medication

Medications