Youth Registration and Permission Form
A monetary donation of $10 is optional but not mandatory
Name
*
Child's First Name
Child's Last Name
Date of Birth
*
Current School Grade
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
Home Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Who has Custody? Please Check:
*
Both
Mother
Father
Other
Medical Concerns? (allergies etc)
Emergency Contact. (Other than Parents)
*
First Name
Last Name
Phone #
*
Format: (000) 000-0000.
Other information leaders should know
Other adults that can pick up my child:
First Name
Last Name
Phone #
Format: (000) 000-0000.
Other adults that can pick up my child:
First Name
Last Name
Phone #
Format: (000) 000-0000.
First Aid and Emergency Medical Treatment:
I recognize that there may be an occasion where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of The Salvation Army to seek and secure any needed medical attention or treatment for the child named above.
Signature of Parent or Legal Guardian
*
Media:
On occasion, The Salvation Army takes photographs or makes an audio or video recording of children and/or adults involved in activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in The Salvation Army publications or advertising materials on and off-line to let others know about our ministry.
Signature Parent or Legal Guardian
*
Release of Liability
By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities offered by The Salvation Army. I also expressly assume all risks of the child or me participating in the activities. I further release The Salvation Army and its staff, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities.I further agree to indemnify and hold harmless The Salvation Army and its staff volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.
I represent that I am the parent/guardian of the above specified child (see child's name), who is under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof.
Signature of Parent or Legal Guardian
*
Date Signed
*
/
Month
/
Day
Year
Date
Retention of personal information:
In order to enrol your child in this program and to keep you informed of updates or changes to this program, this personal information will be maintained indefinitely. This is also for legal and insurance reasons. If you wish Lindsay Salvation Army community church to limit the information gathered or wish to view it at any time please contact us.
Submit
Should be Empty:
