Family Information Form
Adult 1 Information
Adult 1 Name
*
First Name
Last Name
Adult 1 Relationship to Children
*
Adult 1 Gender
*
Adult 1 Email
*
example@example.com
Adult 1 Phone 1
*
Please enter a valid phone number.
Adult 1 Phone 1 Type
*
Please Select
Home
Mobile
Work
Adult 1 Phone 2
Please enter a valid phone number.
Adult 1 Phone 2 Type
Please Select
Home
Mobile
Work
Adult 1 Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Would you like to add another adult to your family profile?
*
Yes
No
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Adult 2 Information
Adult 2 Name
*
First Name
Last Name
Adult 2 Relationship to Children
*
Adult 2 Gender
*
Adult 2 Email
*
example@example.com
Adult 2 Phone 1
*
Please enter a valid phone number.
Adult 2 Phone 1 Type
*
Please Select
Home
Mobile
Work
Adult 2 Phone 2
Please enter a valid phone number.
Adult 2 Phone 2 Type
Please Select
Home
Mobile
Work
Would you like to add a different address for Adult 2?
*
Yes
No
Adult 2 Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Would you like to add another adult to your family profile?
*
Yes
No
Back
Next
Adult 3 Information
Adult 3 Name
*
First Name
Last Name
Adult 3 Relationship to Children
*
Adult 3 Gender
*
Adult 3 Email
*
example@example.com
Adult 3 Phone 1
*
Please enter a valid phone number.
Adult 3 Phone 1 Type
*
Please Select
Home
Mobile
Work
Adult 3 Phone 2
Please enter a valid phone number.
Adult 3 Phone 2 Type
Please Select
Home
Mobile
Work
Would you like to add a different address for Adult 3?
*
Yes
No
Adult 3 Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Child 1 Information
Child 1 Name
*
First Name
Last Name
Child 1 Gender
*
Child 1 Primary Address
*
Please Select
Same as Adult 1
Same as Adult 2
Same as Adult 3
Child 1 Birthdate
*
-
Month
-
Day
Year
Date
Child 1 Grade
*
Please Select
Not yet in school
Preschool
PreK
K
1
2
3
4
5
6
Child 1 School
*
Child 1 Allergies
Child 1 Special Needs
Is there anything else you'd like us to know about your child?
Would you like to add another child?
*
Please Select
Yes
No
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Child 2 Information
Child 2 Name
*
First Name
Last Name
Child 2 Gender
*
Child 2 Primary Address
*
Please Select
Same as Adult 1
Same as Adult 2
Same as Adult 3
Child 2 Birthdate
*
-
Month
-
Day
Year
Date
Child 2 Grade
*
Please Select
Not yet in school
Preschool
PreK
K
1
2
3
4
5
6
Child 2 School
*
Child 2 Allergies
Child 2 Special Needs
Is there anything else you'd like us to know about your child?
Would you like to add another child?
*
Please Select
Yes
No
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Next
Child 3 Information
Child 3 Name
*
First Name
Last Name
Child 3 Gender
*
Child 3 Primary Address
*
Please Select
Same as Adult 1
Same as Adult 2
Same as Adult 3
Child 3 Birthdate
*
-
Month
-
Day
Year
Date
Child 3 Grade
*
Please Select
Not yet in school
Preschool
PreK
K
1
2
3
4
5
6
Child 3 School
*
Child 3 Allergies
Child 3 Special Needs
Is there anything else you'd like us to know about your child?
Would you like to add another child?
*
Please Select
Yes
No
Back
Next
Child 4 Information
Child 4 Name
*
First Name
Last Name
Child 4 Gender
*
Child 4 Birthdate
*
-
Month
-
Day
Year
Date
Child 4 Grade
*
Please Select
Not yet in school
Preschool
PreK
K
1
2
3
4
5
6
Child 4 School
*
Child 4 Allergies
Child 4 Special Needs
Is there anything else you'd like us to know about your child?
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Adult Contact Preference
When we need to reach home, who should we contact? (select all that apply)
*
Adult 1
Adult 2
Adult 3
Emergency Contact
In the event that neither Adult 1, Adult 2, nor Adult 3 can be reached, who would you like us to contact?
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Emergency Contact Phone Type
*
Please Select
Home
Mobile
Work
Emergency Contact Relation to Children
*
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Consent, Release, and Indemnity
I understand that participation in any events at Westminster Presbyterian Church can present a risk of harm to the participant and that I have a personal responsibility for assuming any and all medical, hospital, and related expenses that may result from my own or my child(ren)’s participation in any of events at Westminster Presbyterian Church. I hereby release Westminster Presbyterian Church, affiliated and sponsored organizations, and its personnel, and agree to indemnify and hold harmless the church and its personnel from and against any liability of any nature whatsoever for any injury to myself and/or my child(ren) resulting or arising in any way from my/their participation in any events offered through Westminster Presbyterian Church. I understand WPC provides no medical coverage. Submitting this form acts as your signature for the above statement and states that all above information was completed accurately by the parent or legal guardian of the child(ren) aforementioned on this form.
Photo/Video Release
I understand that by participating in Westminster Presbyterian Church worship and activities, I/my child(ren) may be photographed and/or videotaped. I hereby assign and authorize the producer, Westminster Presbyterian Church, the rights (all rights) in and to such videotape and photography. I also authorize said producer, without limitation, the right to reproduce, copy, exhibit/publish, and distribute any such videotape and/or photographs, and expressly waive any rights or claims I may have against Westminster and/or any of its Affiliates, Subsidiaries, or Assignees except as outlined in this contract. If you have any concerns, please contact Anna Hiner, Communications & Database Manager, at hiner@westminster-church.org or 412-835-6630x207.
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