Salvation Army Pasco Youth Night Registration

Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact
Emergency Contact Full Name

First NameMiddle NameLast Name
Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child(ren) Attending
Child Entry
Parent/Guardian Certification
Photo Release
I give permission for my child(ren) to be photographed and/or recorded during The Salvation Army Pasco County programs, activities, trips, and events. I understand that these images or recordings may be used for ministry, promotional, social media, website, print, or communication purposes.

Transportation Release
I give permission for my child(ren) to be transported by The Salvation Army Pasco County in Salvation Army vehicles or other approved transportation for program activities, field trips, and related events. I understand that reasonable safety precautions will be followed during transportation.

Parent/Guardian Agreement
By signing below, I acknowledge and agree to the photo and transportation permissions selected above and certify that I am authorized to give permission on behalf of the child(ren) listed on this registration.
Parent/Guardian Signature
Date

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