Youth Ministry Event Registration & Medical Release Form & Waiver
Teen's Full Name
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Birthdate mm/dd/yyyy
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Teen'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 teen if he/she is not driving:
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An 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 teen 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 teen's photos):
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Permission granted for all purposes.
Permission granted only for in-house us (slideshows & various church presentations).
Please DO NOT use my teen's photo for any purpose.
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 Youth leader responsible for my teen or their representatives are unable to contact the parent(s) or guardian(s), we hereby grant permission to the Youth leader responsible for my teen or their representatives to administer necessary first aid, and/or to take my teen 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 teen while my teen participates in the Youth Ministries of Utica Church of Christ, Utica Ohio.
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Please click on the checkbox to continue
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YOUTH MINISTRY EVENT REGISTRATION
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