UCC Children's Ministry Registration

Children's Ministry Registration & Medical Release Form & Waiver

Thank you for bringing your child to Utica Church of Christ. Our goal is to teach your child about God (Father, Son, and Holy Spirit), the Bible and godly living. In order to provide the safest environment for you child, we need this form filled out completely. Please complete the form below. If you have questions, call 740-892-3838.

Child's Full Name
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Birthdate mm/dd/yyyy
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Child's Current Age
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Grade Level
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Parents Full Name
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Email Address
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Phone Number
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Address (include PO Box)
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City/Zip Code
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Authorized people to pick up my child (must be 18 years of age or older)
Is there any custodial information that we should be aware of? If so please list below:
Do you have a church home?

Yes
No
If no, would you like to be contacted to learn more about our church?
Yes
No
Any medical concerns that we should be aware of? If so, please list them below:
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Family Doctor & Hospital Preference (in case of an emergency):
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Emergency Contact Information in case you can not be reached (please include names and phone numbers)
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I hereby grant permission for Utica Church of Christ to record pictures or videos of my child while on the church property or at a church-sponsored event. I also give permission to Utica Church of Christ to use these images or videos in church print and online publications including church websites and social networks knowing that their identity is kept anonymous. (Please select your wish for the use of your child's photos):
*

Permission granted for all purposes
Permission granted only for in-house use (slideshows & various church presentations)
Please DO NOT use my child's photo for any purpose
How Did You Hear About VBS?
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Social Media
Ice Cream Festival Parade
Neighbor/Friend/Relative
Church Member
Road Sign/Flyer
Newspaper
Other (Please List Below)
Other From The Form Above
By initialing below, you release Utica Church of Christ and its authorized representatives and staff from liability of any kind and character upon any claim, demand, or cause of action which might be asserted in behalf of said minor against said church, representatives, or staff. Furthermore, in the event of an accident or injury, if the children’s leader responsible for my child or their representatives are unable to contact the parent(s) or guardian(s), we hereby grant permission to the children’s leader responsible for my child or their representatives to administer necessary first aid, and/or to take my child to the nearest medical facility for additional treatment by a physician/medical specialist. In addition, I will notify Utica Church of Christ in writing of any changes in medications, allergies or medical conditions that occur for my child while my child participates in the Children’s Ministries of Utica Church of Christ, Utica Ohio.
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Please click on the checkbox to continue
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CHILD'S MINISTRY REGISTRATION & MEDICAL RELEASE FORM & WAIVER

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