First Presbyterian Church Youth Registration & Liability Release Form

First Presbyterian Church Youth Registration & Liability Release Form

2026-2027
Student's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Student's Cell Phone
Format: (000) 000-0000.
Student's E-mail
example@example.com
Parent/Guardian 1

First NameLast Name
Parent/Guardian 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent Guardian 2

First NameLast Name
Parent/Guardian 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
General health, allergies, medical concerns (if none, please put NA)

If parents/guardians listed above cannot be reached, in case of emergency, please notify:

Rows	Full Name	Address	Contact Number
1
2

Do you grant consent for your student's photo/video to be taken while participating in activities at youth group, and do you authorize First Presbyterian Church to use their image, whether in photo, video, or audio for use in various informational, promotional, and advertising efforts?
Permission Form

I /we also hereby give permission for my student to participate in all activities and travel events sponsored by First Presbyterian Church during this calendar year.

On all trips, a youth group leader will be with your student’s group and can be reached, at most times, by cell phone in the event of an emergency.

Knowing that the adult in charge will take the utmost care of my student’s safety, I understand that accidents do occur and that in such situations immediate steps must be taken to secure my student’s health. I hereby authorize the staff of First Presbyterian Church to seek medical attention for my student 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 shall be held harmless in the event of accident or injury, and in that regard, I understand and agree that First Presbyterian Church disclaims any and all liability in the unlikely event of injuries sustained in connection with these events.

Your signature below also verifies that you have read and answered the above questions to the best of your ability.
Participant's Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If the participant is under the age of 18, the following parent or legal guardian signature is required as well.
Parent/Guardian's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: