2021-2022 YOUTH REGISTRATION FORM

2021 - 2022 YOUTH REGISTRATION FORM

All minors wishing to participate in Montvale Evangelical Free Church (MEFC) activities and programs, including the church nursery, must have their parent or legal guardian complete and sign this form. Information contained within the form will be used to ensure the protection of children who participate in our programs or use our facilities. All information is considered confidential and will be treated appropriately.
YOUTH INFORMATION
Youth's Name *

First Name Last Name
Youth's Date of Birth *

Month Day Year
Date
Youth's Grade *
Youth's Gender *

Male Female
Youth's Address *
Youth's Cell Phone
PARENT / LEGAL GUARDIAN INFORMATION
Parent / Legal Guardian Name *

First Name Last Name
Second Parent / Guardian Name

First Name Last Name
Parent Email Address(es) *
List all phone numbers where the parent / guardian can be reached *
Name, Number, Type (home, cell, work)
Other Emergency Contact
Name, Number, Relation
MEDICAL INFORMATION
Insurance Company
Insurance Company Phone
Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's ID Number
Group Number
Youth's Primary Care Physician
PCP's Phone
Name of Practice
Date of Last Tetanus Shot
Preferred Hospital in Case of Emergency
MEDICAL HISTORY AND CONDITIONS
List any medical history or conditions (e.g. asthma, diabetes, seizure disorder) for the youth
List any allergies (drug/medicine, food, environmental, etc.) and the severity/type of reaction
List any medications being taken
Please explain any other pertinent information about the youth (i.e. physical, behavioral, emotional) that would be important for the adult leaders to know
MEDICAL TREATMENT AUTHORIZATION
I understand that in the case of a medical emergency involving my child / youth, I will be notified. However, in the event that I cannot be reached, I authorize MEFC to seek and obtain necessary medical treatment in the event my child is injured or becomes ill. This may include emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment or hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. *

Yes No
I understand that MEFC will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent / guardian. I will be liable and agree to pay all costs and expenses incurred in connection with such medical and/or dental services rendered to the minor pursuant to this authorization. *

Yes No
I agree to notify MEFC in the event of any health changes which would restrict my child or youth’s participation in any activities. I also understand the adult leaders reserve the right to restrict my child from any activity where they do not feel it is within the physical capabilities of my child / youth.

Yes No
I do hereby agree to hold MEFC, and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my/our child or property, even injury resulting in death, which I now have, my minor child has, or which may arise in the future in connection with any medical treatment deemed necessary and authorized by MEFC’s representative in his/her exercise of the terms of this Medical Treatment Authorization.
Parent / Legal Guardian Signature *

Clear
PHOTO & VIDEO CONSENT AND RELEASE
From time to time, MEFC may photograph and take video recordings of child / youth during church-related activities and programs. This release grants MEFC the right to use and re-use, publish and re-publish, and modify or alter images (photographs, digital images, video or other recordings) taken during the shoot. Use of the images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the images and release and discharge MEFC from any and all claims arising out of use of the images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.
I have read the above statement and:

Yes, I fully understand and agree to its consent. No, I do not wish for my youth's photo to be used in any regard.
Parent / Legal Guardian Signature *

Clear
TRANSPORTATION CONSENT
I give permission for my child / youth to ride in any vehicle driven by an approved and licensed adult leader or chaperone while attending and participating in off-site activities sponsored by MEFC. My child / youth and I understand that seat belts must be worn at all times during transportation.

I understand and hereby agree to assume all of the risks which may be encountered with said transportation. I do hereby agree to hold MEFC and its and their agents and employees, including Driver, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to me or my property which I now have or which may arise in the future in connection with my transportation for Church activities as a convenience to me.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of New Jersey and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement that I have read and understand.

If you do not agree, write ‘No’ in the signature line.
Parent / Legal Guardian Signature *

Clear
SUPPLEMENTAL MEDICAL CONSENT
As part of the MEFC Youth Groups, a youth may attend an off-site activity or program such as a field trip, retreat, camping, hiking, sports events, mission’s trips and any other activity normally associated with youth ministries. All off-site activities will require a parent / legal guardian signed permission form specific to the activity or event prior to the youth being permitted to participate.

In addition to the information already provided, please complete the following sections:
Do you give permission for your child / youth to be given over-the-counter medication as needed and as directed on the label to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache or allergic reaction (e.g. Tylenol, Advil, antacids, Benadryl) while at a child / youth activity or program?

No. Contact me or get medical help if my child has any minor medical concerns. Yes. I give permission for an adult leader to give my child approved over-the-counter medications.
List all medications the youth will take during any youth ministry trips, retreats or events. This includes any prescription, non-prescription, herbal supplements and/or vitamins. Any youth participant is required to give ALL MEDICATIONS to the adult leader in their original containers with complete dispensing information before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and MEFC reserves the right to send the youth participant home, at the parent / guardian’s expense, if they do.
Medication Name / Dose / Treatment For / Dispensing Instructions
COVENANT OF EXPECTATIONS
All youth and youth leaders / chaperones participating in MEFC activities or programs whether on-site or off-site must abide by the MEFC Covenant of Expectations.  The following rules and guidelines are equally binding on adult leaders / chaperones and youth.

Non-Negotiable Rules

Any participant failing to abide by these rules, in accordance with the MEFC Youth Ministries Code of Conduct, may be sent home at personal or family expense.

·         No use of illicit drugs or alcohol.
·         Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions.
·         No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments)
·         Must be in assigned rooms by designated time
·         Coed visitation only in assigned community room
·         Smoking and the use of tobacco products are not allowed to, from, or during any trip
·         Will not break any American laws in the United States or any other country

Guidelines for Living in Christian Community

·         Adults and youth will be equally responsible for performing assigned tasks in a timely and cooperative manner
·         Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times, recognizing Christ’s presence in each other
·         Participants will be respectful of both common living spaces and the property of others
·         Participants will avoid the use of foul language, cursing, or any speech (including ‘humor’) which puts down, makes fun of, or stereotypes other persons or groups.
·         Sleeping areas for males and females will be separate
Youth Statement: By signing this form, I pledge to honor God and respect others during activities and programs by following the rules and guidelines stated above. I understand that I cannot participate in the activity or program unless this completed form is on file.
Youth Signature *

Clear
Parent / Guardian Statement: By signing this form, I agree to support the Covenant of Expectations printed above, and will accept responsibility for the payment of my child’s return transportation should he/she break one of the non-negotiable rules.
Signature *

Clear
PARENT / LEGAL GUARDIAN CONSENT & RELEASE
This consent must be completed on behalf of all Children and Youth who participate in MEFC activities and programs.

I, the undersigned, being the parent or legal guardian of the child named in this document, do hereby consent to the participation of my child in all of the regularly scheduled activities of the Children’s and Youth ministries at Montvale Evangelical Free Church.

In consideration of MEFC allowing my child / youth named in this document to participate in children / youth ministry (Sunday School, King’s Kids, Boy’s Brigade, Events, Retreats, Mission’s Trips, etc.) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless MEFC, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child / youth participant while involved in child /youth activities and/or childcare.

I, the parent or legal guardian of this child / youth participant, grant my permission for the child / youth named in this document to participate fully in children / youth ministry activities and childcare, including trips away from church premises.

Furthermore, I, on behalf of my minor participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of the child or youth participant, including expenses incurred attendant thereto.

I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the law of the States of New Jersey and New York and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further agree that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that I have read and understand.
Name of Youth *

First Name Last Name
Name of Parent / Legal Guardian *

First Name Last Name
Parent / Legal Guardian Signature *

Clear
Date / Time
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2021 - 2022 YOUTH REGISTRATION FORM

YOUTH INFORMATION

PARENT / LEGAL GUARDIAN INFORMATION

MEDICAL INFORMATION

MEDICAL HISTORY AND CONDITIONS

MEDICAL TREATMENT AUTHORIZATION

PHOTO & VIDEO CONSENT AND RELEASE

TRANSPORTATION CONSENT

SUPPLEMENTAL MEDICAL CONSENT

COVENANT OF EXPECTATIONS

PARENT / LEGAL GUARDIAN CONSENT & RELEASE