SWARTHMORE PRESBYTERIAN CHURCH - CHILDREN & YOUTH REGISTRATION 2026-27
Child/Youth Name:
Grade:
DOB:
I hereby give permission for my child (named above) to participate in Swarthmore Presbyterian Church (SPC) activities from September 1, 2026, to August 31, 2027, and release SPC from any and all liability to me or my child as a result of their participation. I understand that SPC does not assume any responsibility for loss of, or damage to, personal property of participants. In case of emergency, if I cannot be reached, I give my permission to the adult leaders of an event to permit hospital personnel and/or a licensed physician to perform emergency treatments and inject or administer medications in conjunction with such emergency treatment.
Signature of Parent or Legal Guardian:
Date:
-
Month
-
Day
Year
Date
Photo & Video Release
Please Select One:
I agree to allow the use of photos or videos from SPC activities in SPC publications, including social media. Minors will not be identified.
OR
I do not agree.
Parent/Guardian Information
Adult 1
Name
First Name
Last Name
Relation to Child:
Cell:
Format: (000) 000-0000.
Home:
Format: (000) 000-0000.
Email:
example@example.com
Street address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City, State, Zip:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Adult 2
Name
First Name
Last Name
Relation to Child:
Cell:
Format: (000) 000-0000.
Home:
Format: (000) 000-0000.
Email:
example@example.com
Street address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City, State, Zip:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Child/Youth Information
Legal Name: (first last)
Preferred Name:
Cell Phone:
Format: (000) 000-0000.
Allergies:
Email:
example@example.com
Food Restrictions:
Medications:
Street Address
City, State, Zip
What else should we know about your child?
Other Information:
Who else may pick up this child from church events?
Godly Play Children: At the end of Godly Play, may your child go to Fellowship Hour unattended? (Select One):
Yes
No
Youth: Do you give permission for your child to leave Youth Group and go Home unattended? (Select One):
Yes
No
Insurance Carrier:
Plan Code:
Identification Number:
Group Number:
Primary Carrier (person under whose name the coverage exists):
After completing this form, please: Save it on your computer, or choose "print to PDF." Name the file with the child's name, (i.e. Searight, Ella) and email to Kathy Josselyn, kathy.josselyn@swarthmorepres.org OR fill in the hard copy version and drop it off in the church office or at any Sunday activity for children or youth.
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