Youth Group Permission Form

First Congregational Church of Southington Youth Group

2023-2024
Child Information
Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Current Grade *
Medical Information: Please list any allergies and/or other health concerns.*
In case of an emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give FCCS my permission to act on my behalf in seeking emergency treatment for my child in the event that such treatment is deemed necessary. I give permission to those administering emergency treatment to do so, using those measures deemed necessary. I release First Congregational Church of Southington from liability in acting on my behalf in this regard. *
Type in initials above.
Special Concerns: In order to provide the best youth group experience we can, please use the space below to make us aware of any special needs your child may have. You can also discuss any concerns you may have directly with Pastor Laura Kisthardt. All information is held in confidence.
Parent/Guardian Contact Information
Parent/Legal Guardian Name 1*

First NameLast Name
Contact Phone Number 1*
Contact Email 1*
example@example.com
Contact Address 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the address above the same as the child.*

YesNo
Parent/Legal Guardian Name 2

First NameLast Name
Contact Email 2
example@example.com
Contact Phone Number 2
Contact Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the address above the same as the child(ren).

YesNo
Are there any persons to which the child (children) may NOT be released to?*

YesNo
Who may your child (children) NOT be released to?
Emergency Contact 1 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 1 Phone Number*
Relationship to child(ren)
Emergency Contact 2 (other than parent/guardian listed above)

First NameLast Name
Emergency Contact 2 Phone Number
Relationship to child(ren)
Media Release

In order to share the good news of the mission and ministry of First Congregational Church of Southington, we occasionally use images (photo/video) of students in youth group or during special programs, or sent to FCCS by parents/guardians. These images may be shared on church bulletin boards, newsletters, in local newspapers or other printed materials, on our website, social media (email communications, live-stream events, Facebook, Instagram, YouTube, etc.), or in presentations during worship. If you are comfortable with the use of your child/ youth’s images for these purposes, please indicate below.
I hereby give permission for First Congregational Church of Southington to take and use images of my child/youth (photo or video) taken during church-related activities, or shared by me with FCCS staff, for church purposes only as described above. No child/youth will be identified by name. I understand that I will be contacted for special permission should any photo be considered for use other than described above.*

I AgreeI Disagree
Should be Empty:

First Congregational Church of Southington Youth Group

Child Information

Child

Parent/Guardian Contact Information

Media Release