Children and Youth Participation Form — Union Christian Church

Children and Youth Participation Form

Participant Information

Name

First Name

Last Name

Date of Birth

YYYY

Age

Gender

Grade in School

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Participant Email Address (If applicable)

Parent/Guardian Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact 1

Name

First Name

Last Name

Phone

(###)

###

####

Relationship to Participant

Emergency Contact 2

Name

First Name

Last Name

Phone

(###)

###

####

Relationship to Participant

Medical Information

Insurance Company

Insurance Company Phone

(###)

###

####

Policy and/or Group Number

Primary Care Physician

Primary Care Phone

(###)

###

####

Subscriber Name

First Name

Last Name

Subscriber Date of Birth

YYYY

Subscriber Phone

(###)

###

####

Allergies or Other Conditions

List of Medications (Dose & Other Instructions)

* Photo/Video Consent: I understand that photographs, audio recordings and video recordings may be created during the event(s) and by initialing I give permission for Union Christian Church to use any or all recordings of me or my child in publications, videos, website design, or other media expressions. Please initial in the text box below if you agree.

I, the undersigned parent or legal guardian, do give consent for the above-named minor to participate in the activities of the Children and Youth Ministry of Union Christian Church during 2023-2024 church year. I understand that said activities will occur both on and off of the property of the church and may include traveling within the State of Georgia and between states by various modes of transportation, including but not limited to: rented van or bus, chartered bus, and personal vehicles. Typing your name below is considered a legal signature.

I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) give permission for an attending physician or hospital to administer medical care if deemed necessary by a physician. I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) hereby release from all claims and forever hold harmless the directors, employees, volunteers and agents of Union Christian Church from any and all claims and demands for personal injury, sickness and death as well as property damage and expenses, of any nature incurred by myself (or my child under 18 years of age). I assume personal responsibility for any loss of property incurred by myself (or my child under 18 years of age) at the event by theft or otherwise. I also assume personal responsibility for all medical bills (for myself or child under 18 years of age). Further, should it be necessary for me or my child to return home due to disciplinary action, for medical reasons, or otherwise, I hereby assume responsibility for all transportation costs. Typing your name below is considered a legal signature.