S'MOREs 2023 Registration Form
This is the Parental Consent form for our 2023 Summer Mission Trip for High School Students. This form is mostly for emergency contact information, and is necessary for your child/youth to be able to participate on the S'MOREs Trip. (Incoming freshmen are included!)
June 11th-18th
Cost is $400. First deposit of $200 is due when you register. The final deposit of $200 is due by May 15th. You can make a check out to 'WPC' with "S'MOREs Trip" in the memo and drop it off or mail it to us.
Children/Youth Information
If you have more than one child/youth coming, you can add additional children/youth at the end!
Name of Child/Youth
*
First Name
Last Name
Current Grade (as of 2022-2023 School Year)
*
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Graduated Senior
Birthday
*
-
Month
-
Day
Year
Date
Identifying Gender
T-Shirt Size
*
Youth's Cell:
Please enter a valid phone number.
Format: (000) 000-0000.
Are you interested in a scholarship?
*
Yes
No
Back
Next
Emergency Contact 1
In the case of an emergency, this will be the first person we try to contact. In addition, this is the person we will contact first about S'MOREs trip information.
Emergency Contact 1:
*
First Name
Last Name
Relationship to Child/Youth
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Emergency Contact 2
In the case of an emergency, this will be the second person we try to contact.
Emergency Contact 2:
*
First Name
Last Name
Relationship to Child/Youth
*
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical Information & Waiver
Physician's Name
First Name
Last Name
Physician's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company
Allergies/Special Health Considerations
This information may be shared with Christian Education & Youth Ministry Staff/Volunteers if deemed important. 'None' is an acceptable answer.
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child/children and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
*
I agree
I disagree
I give permission for my child/children to participate in activities at the church and go on field trips sponsored by the church. I release Worthington Presbyterian Church and individuals from liability in case off accident during activities related to Worthington Presbyterian Church, as long as normal safety procedures have been taken. I understand that my child/children may participate in activities that will require them NOT to be supervised by an adult but will be in a small group and will be required to check in at regular times.
*
I agree
I disagree
Permission to Use Photos: I give permission for the church, whether that being ministers, staff, leadership and/or volunteers to use photos of my child/children in church publications such as church newsletters, church website, or other church related needs.
*
I agree
I disagree
E-Signature
*
Date:
*
Back
Next
Have Additional Youth?
If you just have one youth, you may hit submit! If you have more than one, you can save some time by adding multiple youths here instead of filling out multiple forms.
Submit
Name of Child/Youth (2)
First Name
Last Name
Grade
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Identifying Gender
Name of Child/Youth (3)
First Name
Last Name
Grade:
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Identifying Gender
Name of Child/Youth (4)
First Name
Last Name
Grade
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Identifying Gender
Name of Child/Youth (5)
First Name
Last Name
Grade:
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Identifying Gender
Submit
Should be Empty: