Pioneer Clubs Registration Form

Child's Name*

Gender

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate*

School Attended

Grade*

Medical concerns or allergies (please put "none" if this doesn't apply):*

Parent's Information*

	Full Name	Email Address	Contact Number
Mother/Guardian
Father/Guardian

Trusted Persons--These people have my permission to drop off and pick up my child from club. [This could also include an older sibling (grade 5 or above), if desired.]

	Name	Relationship	Contact Number
1
2
3
4

Other Emergency Contacts--These people may be contacted in case of an emergency if I cannot be reached.

	Name	Relationship	Contact Number
1
2

Do you grant consent for your child’s photo/video to be taken while participating in activities at Pioneer Clubs, and do you authorize First Presbyterian Church to use their image, whether in photo, video, or audio for use in various informational and promotional efforts?*

YesNo

E-Signature of Parent or Legal Guardian

Your typed electronic signature above verifies that you have read and answered the above questions to the best of your ability.

Pioneer Clubs Basic Code of Conduct and Discipline

E-Signature of Parent or Legal Guardian for Code of Conduct

Your typed electronic signature above verifies that you have read, are in agreement, and will give full cooperation with the expectations and consequences as described above.

FIELD TRIP PERMISSION FORM

Pioneer Clubs at First Presbyterian Church of South Charleston periodically travels to local homes, areas of interest, places of business, and other special attractions for the educational purposes of a group field trip. By signing this BLANKET PERMISSION FORM, you give permission for your child to attend these activities for this club year. On all trips, a Club Leader will be with your child’s group and can be reached, at most times, by cell phone in the event of an emergency. The Club Coordinator will know where the Club is in the event you need to reach your child.

Knowing that the adult in charge will take the utmost care of my child’s safety, I understand that accidents do occur and that in such situations immediate steps must be taken to secure my child’s health. I hereby authorize the staff of First Presbyterian Church South Charleston to seek medical attention for my child should an emergency arise, provided that I will be contacted as soon as possible. Failure to reach me shall not prevent an application of immediate, necessary medical treatment, not excluding injection, anesthesia, or surgery. I further agree that First Presbyterian Church of South Charleston shall be held harmless in the event of accident or injury and, in that regard, I understand and agree that First Presbyterian Church of South Charleston disclaims any and all liability in the unlikely event of injuries sustained in connection with these events.

E-Signature of Parent or Legal Guardian for Field Trips

Release Form

FOR PARENTS OF FIFTH/SIXTH GRADERS:

My fifth/sixth grade student has my permission

to be released at the end of Club without a parent present.
to pick up their younger sibling(s) at their sibling's classroom.
to be listed as a Trusted Person for my younger children.

I agree that First Presbyterian Church of South Charleston shall be held harmless in the event of accident or injury and, in that regard, I understand and agree that First Presbyterian Church of South Charleston disclaims any and all liability in the unlikely event of injuries sustained in connection with this event.

Reminder to Parents: The above students are to leave the premises or enter their vehicles immediately. For safety reasons, they may not roam around the Fellowship Hall or parking lot.

Fifth/sixth grade student to be Self-Released

Names of younger siblings to be picked up (if any)

E-Signature of Parent or Legal Guardian for Fifth/Sixth Grader

Your typed elctronic signature above verifies that you have read and answered the above statement and are in agreement.