Children + Youth Registration

Family Information

Parent/Guardian 1

Parent Name

This address will receive a confirmation email

Mobile Phone

Address

Parent/Guardian 2 (if applicable)

Parent Name

This address will receive a confirmation email

Mobile Phone

Address (if different than Parent/Guardian 1)

Child's Information

Name

Nickname

Birthdate

School

Allergies

Does your child have accessibility needs or is there any other information that would assist us in working with your child?

Permissions

For each statement below, please check Yes, No, or NA (Not Applicable). For any statement for which you check YES, please add today's date in the box below to confirm your agreement.

I hereby give permission for the child listed to participate in activities or programs offered by Rock Spring Congregational UCC’s Sunday School program that are held at the church or for which the church will provide transportation.

Yes No

Sunday School Participation

I give permission for pictures of my child to be used in communications internal to Rock Spring including Rock Spring News, All Church Email, TW@RS emails, and posters that may be placed on the premises. I understand that my child's name may be used in association with these types of communications.

Yes No

Photo Release

(for 6th-12th grade youth) I hereby give permission for the individual listed to participate in activities or programs offered by Rock Spring Congregational UCC’s Youth of Rock Spring (YoRS) program that are held via Zoom, at the church*, or for which the church will provide transportation*. I also authorize the Adult Leaders and Chaperones to sign as the responsible adult for the above-listed child in connection with third party recreational providers such as ski, canoe, kayak outfitters, or transportation providers.

Yes No NA

YoRS Participation

(for 6th-12th grade youth) I hereby give permission for any necessary emergency medical treatment to be administered at the discretion of the group leaders or trained medical professionals, and for any health care information to be shared with the same. I also accept any and all financial obligations that arise from such treatment. I hereby waive Rock Spring Congregational UCC and any event leaders from liability in the case of an emergency.

Yes No NA

YoRS Medical Release

(for 6th-12th grade youth) Insurance Company + Policy/Group Number

(for 6th-12th grade youth) Primary Care Dr. + Phone Number

Children + Youth Registration

Description

Please Fix the Following