Youth Group Registration 2018-2019
Please fill out this form and click submit.
Parent/Guardian Name
*
Relationship to Child(ren)
*
Parent/Guardian Phone
*
Alternate Phone Number
Parent/Guardian Email
*
I would like to be added to Pastor Paul's weekly email list
*
Please select one option.
Yes
No
I already receive emails
Parent/Guardian Address
*
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Parent/Guardian 2, If applicable
Parent/Guardian 2 Relationship to Child(ren)
Parent/Guardian 2 Phone Number
Parent/Guardian 2 Email Address
I would like to be added to Pastor Paul's weekly email list
Please select one option.
Yes
No
I am already subscribed
Parent/Guardian 2 Address, if different from above
Other safe adults who are authorized to pick up your child(ren), if any
Insurance Company
*
Insurance Co. Phone Number
*
Policy Number
*
Group/Plan Number
*
Policy Holder ID Number
Doctor Name
Doctor Phone
Student Name
*
Student Birthdate
*
Grade for 2018-2019 School Year
*
Please select one option.
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
5th Grade
Select Option
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
5th Grade
School Attending
*
Please list any allergies, medical conditions, or learning or psychological differences, as well as how we can best equip your child (this information is confidential). If none, enter
*
Date of Last Tetanus shot
*
Name of Child 2
Birthdate of Child 2
Grade for 2018-2019 School Year
Please select one option.
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Select Option
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Name of 2nd Child's School
Please list any allergies, medical conditions, or learning or psychological differences, as well as how we can best equip your child (this information is confidential). If none, enter
Date of Last Tetanus Shot
I understand that by participating in Aldersgate activities, my child may engage in various games, activities, and service projects. These activities may include transportation by a qualified adult. Proper safety precautions will be taken for all activities. In consideration of accepting these activity and/or transportation services, I hereby for myself and heirs, waive any and all rights and claims for damages I may have against Aldersgate UMC and its representatives, for any and all injuries from whatever cause suffered by the below child(ren) in the course of the activity or transportation service provided. In the case of an emergency, Aldersgate UMC representatives have my permission to use their judgment with regard to treatment until I can be contacted.
*
Please select one option.
Yes
No
Name of parent or guardian (by entering my name, I acknowledge and agree to the above liability release)
*
We take pictures and videos of students doing projects or activities from time to time, and use them for slides, videos, and other promotional materials, which may include social media. Do you give Aldersgate United Methodist Church the rights to use images of your child for these purposes?
*
Please select one option.
Yes
No
Submit
Description
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