Port Community Church YOUTH Events & Waiver
118 Main Street, Port Republic, NJ 08241 ALL ARE WELCOME so PASS THE WORD!
IF YOU HAVE ANY QUESTIONS, CONTACT THE COORDINATORS
FALL YOUTH EVENT DATES: 2nd Friday of each month and Saturday.
Friday, September 11th
Saturday, September 26 @ 10AM
Friday, October 9th
Saturday, October 17th @ 10AM
Friday, November 13th
Saturday, November 21st @ 10AM
Friday, December 11th
Saturday, December 19th @ 10AM
Name
*
First Name
Last Name
BIRTHDATE
-
Month
-
Day
Year
Date
GRADE 2026-27 School Year:
GRADE 4
GRADE 7
GRADE 5
GRADE 8
GRADE 6
Other
Youth Phone Number (if applicable)
Please note all communications between youth and the church will be visible to parents at all times.
Format: (000) 000-0000.
Youth Email (if applicable)
Please note that all communications through email with your youth will also come to parent.
Guardian 1 - Name
First Name
Last Name
Guardian 1 - Relationship to Youth
IE: Mother; Father; Grandparent; etc.
Guardian 1 - Phone Number
Format: (000) 000-0000.
Guardian 1 - Email
example@example.com
Guardian 2 - Name
First Name
Last Name
Guardian 2 - Relationship to Youth
IE: Mother; Father; Grandparent, etc.
Guardian 2 - Phone Number
Format: (000) 000-0000.
Guardian 2 - Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMERGENCY CONTACT
First Name
Last Name
CONNECTION TO YOUTH?
IE: Mother; Father; Grandparent, etc.
EMERGENCY CONTACT PHONE NUMBER:
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any medical conditions or concerns. Any medications. Any allergies.
Please list any social or emotional concerns or circumstances that would help us best serve your youth.
#1. Pictures and videos will be taken during youth activities at Port Community Church. These may be used for use on church social media, and I hereby give my permission for my youth to be included in the pictures. Please Initial Below:
#2. Medical Release: I (We), the parent(s) or guardian(s) of the above listed child(ren) grant permission for our child(ren) to participate in youth activities at Port Community Church and to receive medical treatment if necessary. If I (we) or the listed child care provider or emergency contact cannot be reached, I (we) give our permission to the staff to secure the services of a licensed physician to provide necessary care, including anesthesia, for my child's well-being. Please Initial Below:
#3. Liability Release: I (we) also release and agree to hold harmless Port Community Church and all its participants from any liability and assume all risk of injury, damage or expenses as the result of participation in activities in youth activities. Please Initial Below:
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: