REVIVE - Youth Registration Form

Youth Registration Form
By completing this registration form, you are giving your child permission to participate in REVIVE.

REVIVE exists to help urban youth follow Jesus.

We run regular after-school programming in addition to summer camps and retreats for students at Hope Academy in order to create a safe context for youth to study God's Word, to build healthy friendships, and to connect with godly mentors.

REVIVE meets Tuesdays from 4:30-7:00pm at Hope Academy.

Our ministry is run by a team of staff & volunteers who love Jesus and want to share the good news of the Jesus with the youth of our city. All members of the REVIVE team are members of like-minded local churches and are thoroughly screened and trained for this work.

Questions: Frank Schmidt - REVIVE Director, (715) 937–0064

Habla Espanol - Tony Dominguez (612) 545-8880

Learn more about REVIVE at: cityjoy.org/revive.

While REVIVE is not officially a program of Hope Academy, we are a closely aligned ministry partner and our programming is currently limited to Hope Academy students.
Participant Information
Child #1 Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Biological Sex
Child's Current Grade
List any medical conditions/allergies, dietary restrictions (e.g., gluten free, dairy free, no pork), or physical activity restrictions.
Would you like to register a second child?
Child #2 Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Biological Sex
Child's Current Grade
List any medical conditions/allergies, dietary restrictions (e.g., gluten free, dairy free, no pork), or physical activity restrictions.
Would you like to register a third child?
Child #3 Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Biological Sex
Child's Current Grade
List any medical conditions/allergies, dietary restrictions (e.g., gluten free, dairy free, no pork), or physical activity restrictions.
Would you like to register a fourth child?
Child #4 Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Biological Sex
Child's Current Grade
List any medical conditions/allergies, dietary restrictions (e.g., gluten free, dairy free, no pork), or physical activity restrictions.
Emergency Contact
Parent/Guardian Name

First NameLast Name
Phone Number
E-mail
Address

Street Address

Street Address Line 2

CityState

Zip Code
Required Waivers
Medical Treatment, Liability & Photo Release Waiver
I, the undersigned parent or guardian of the PARTICIPANT listed above, who is a minor, do hereby authorize adult workers of REVIVE to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment, on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful.

I further release, forever discharge and agree to hold harmless REVIVE (a ministry of CityJoy), its volunteers and staff, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above-named child that occur during any activities.

I hereby grant REVIVE permission to use photographs of PARTICIPANT in any of the following: Web-based publications, print advertisements, organization bulletin, social media platforms. I hereby affirm that such release to REVIVE does not constitute any form of compensation. I understand and agree that photographs in the possession of the REVIVE shall become the property of REVIVE.
I have read the above waivers/releases and understand what I have read. I represent that I am the participant named above (if 18 or over) or the legal parent/guardian of the child named above, who is under 18 years of age. In consideration of allowing my child to participate in this activity and ongoing REVIVE activities, I hereby consent to the foregoing on behalf of my child and agree that this release shall be binding upon me, my child, our heirs, legal representatives and assigns.
Signature of Parent/Guardian:
Date

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

Youth Registration Form

Participant Information

Emergency Contact

Required Waivers

Medical Treatment, Liability & Photo Release Waiver