Authorization to Participate
2019/2020 Program Year
Family Information
Parent/Guardian #1
*
First Name
Last Name
Parent/Guardian #2 (Optional)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone #1
*
-
Area Code
Phone Number
Contact Phone #2
-
Area Code
Phone Number
Can receive texts:
*
Yes
No
Can receive texts:
Yes
No
Email #1
*
example@example.com
Email #2
example@example.com
Are you a member of Glenshaw Presbyterian Church?
*
Yes
No
If you answered "No" above, then please list your current church affiliation:
Emergency Contact Information
In the unlikely event of an emergency, and the above listed parent/guardian is not available, please contact the following person(s):
Emergency Contact #1
*
First Name
Last Name
Emergency Contact #2 (Optional)
First Name
Last Name
Relationship to student:
*
Relationship to student:
Contact Phone Number:
*
-
Area Code
Phone Number
Contact Phone Number:
-
Area Code
Phone Number
Participant Registration
Please list all the children you wish to register at GPC. Please note that you may only register children for which you are the legal parent/guardian.
Child #1
*
Child #2
Child #3
Child #4
Are all the above up to date on vaccinations?
*
Yes
No
Is there any other information we should be aware of?
Authorized Pick-Up
To best ensure the safety of all participants, please note person(s) approved to pick-up your children from GPC, other than the parent(s)/guardian(s) listed above. No other persons will be allowed to take the above listed children from the GPC campus without expressed written consent from the parent/guardian. You may add/remove authorized persons by submitting their names in writing to Justin Weilnau.
Authorized Person #1
First Name
Last Name
Authorized Person #2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
Photography Release
Glenshaw Presbyterian Church has my permission to use my child’s photograph publicly in GPC materials. I understand the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Parent/Guardian Signature
*
Participation Authorization
To the best of my knowledge, all the above listed health information is correct. I give permission for the above listed children to participate in the programs at Glenshaw Presbyterian Church. I authorize GPC personnel to administer emergency diagnostic and therapeutic procedures as may be necessary for my child/children, and I authorize that such treatment to be carried out by a local hospital in the event of an emergency. I understand that I am responsible for all costs incurred for such treatment.
Parent/Guardian Signature
*
Submit
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