Park Hill Youth Group Registration Form
Youth Information
Youth Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
Insurance Provider Name
Medical Insurance #
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
Parent/Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship
Payment Details
Payment Method
Please Select
Cash
Check
Credit Card
Bank Transfer
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
Repeated offenses by your youth may result in suspension or expulsion.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.
By signing below, I authorize the youth group leaders to seek and secure emergency medical treatment for my child in the event of an emergency when I cannot be reached. I understand that I will be responsible for any medical expenses incurred.
I release this organization from any and all liability from accident or injury to the child during the organization related events.
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: