Youth Group Form 2018-19

Basic Information

Student Name*

First Last

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Email

If available

Student Phone Number

If available

Student Birth Date*

Gender

Grade*

Medical Information

Insurance Company*

Policy Number*

Group Number*

Family Doctor Name*

Allergy and Medical Information *

Medications Taken (OTC and Prescription) *

Any other pertinent information we should know?

Parent Information

Parent Name *

First NameLast Name

Parent Phone Number*

Area CodePhone Number

Parent Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Liability Release:

I, the undersigned, being the parent or legal guardian of the child named above (herein after "the child"), do hereby consent to the participation of my child in all of The First Presbyterian Church of West Chester Youth ministry events for the year of September 2022 through September 2023. This includes activities both on and offsite, including but not limited to mission trips and retreats. Further, I certify that my child is physically fit to participate in these activities. I also understand that I will be notified in the case of any medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing necessary medical services in the event that my child is injured or becomes ill. I understand neither First Presbyterian Church of West Chester, nor the ministry staff/volunteers may be held responsible for medical expenses incurred, but that such expenses will be my responsibility as the parent/guardian.

I (Parent) understand the following disclaimer: As with the use of any public or other facility outside of the home, use of First Pres Youth Ministry Events may expose you/your child to the COVID-19 virus. Your decision to attend/your child to attend Youth Ministry Events and abiding by published safety is made knowingly and voluntarily by you with the full knowledge of this risk. Your use of FPCYM Event Facilities constitutes a waiver which releases First Pres Youth Ministry and Event Sites from any and all liability with respect to exposure of the COVID-19 virus. If you disagree with this waiver, please do not attend First Pres Youth Ministry Events and Event Sites.

Photo Release:

I, also grant permission to First Presbyterian Church of West Chester to publish pictures & videos of myself and/or the minor named above on the First Presbyterian Church of West Chester website, in promotional videos, press releases, or any other form of public publicity.

Rules and Expectations:

I also understand that all participants are expected to adhere to the following rules:

1. No use or possession of tobacco products, alcohol, or illegal drugs.

2. No use of inappropriate language will be permitted.

3. Cell phone use will be limited.

4. No leaving activity locations without permission of a leader.

5. Inappropriate displays of affection will not be permitted.

6. Participation with the group is expected.

7. No offensive or immodest clothing.

6. No disrespect to the adult leaders or other students will be tolerated.

I have completed the above, and have read these ruled and understand that if there are any discipline problems with my child, that I am responsible for picking up my child from any activity of First Presbyterian Church of West Chester at any time and location necessary.

Student Signature*

Parent Signature (if student under 18)*

Youth Group Form 2022-23