Youth Registration & Consent Form 2023
2023/2024 | Please register your child for participation in any youth activities for this school year.
Youth Information:
Name
*
Mobile Phone
Birth Date
*
Grade
*
Please select all that apply.
6th
7th
8th
9th
10th
11th
12th
School
*
Address
*
Student Cell Phone
Student Email
Allergies/Medical Conditions
*
Parent or Guardian's Information:
First and Last Name
*
Email
*
This address will receive a confirmation email
Mobile Phone
*
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Second Parent or Guardian's Information:
First and Last Name
*
Email
*
Mobile Phone
*
Address
*
Additional Information:
Emergency Contact (Other than Parent or guardian
*
Emergency Contact Cell Number
*
T-Shirt Size (Adult Sizes)
*
Please select one option.
Small
Medium
Large
X-Large
Select Option
Small
Medium
Large
X-Large
Consent and Certification:
By typing your name below, you give permission for your child to attend and participate in activities and events sponsored by Powell United Methodist Church to be held on church premises and/or at off-site locations. I understand that I will be notified of specific details for all off-site activities/events. This permission is granted for the 2023-24 program year (7-1-2023 to 8-31-2024). We authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Every attempt will be made to notify parents or guardians before procedures proceed. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connections with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reason, disciplinary action or otherwise, we (I) hereby assume all transportation costs. The undersigned does also herby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Powell UMC. The undersigned does also herby give permission for Powell UMC, ministers, staff, leadership and/or volunteers to use photos of my child in church publications such as church emails, church website, Facebook or other church related needs. The undersigned does also herby give permission for the church to contact my child via email and/or text messages as a means of communication. Please type your full name below.
*
Date:
*
Youth Pledge:
I hereby pledge to uphold all policies of the Youth Ministries of Powell UMC. During all youth activities and all youth trips, I pledge to follow all instructions of the youth leader and the adult chaperones, including safety instructions. (Youth will sign)
*
Date:
*
Submit
Description
2023/2024
Please register your child for participation in any youth activities for this school year.
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