2020-2021 Highland United Methodist Youth Registration Form
Please fill out this form and click submit.
Student Biographical Info
Student's Name
*
Student Email
*
This address will receive a confirmation email
Student Phone
*
Address
*
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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
Birthday
*
Parent Or Legal Guardian
Parent Name
*
Parent Name
Parent Phone
*
Alternate Phone
Parent Email
*
This address will receive a confirmation email
Alternate Email
This address will receive a confirmation email
Permission to Participate and Photo Release
The parent or legal guardian of the child named below, a minor child, does hereby grant permission for said child to engage in the various activities sponsored by Highland United Methodist Church for its Youth Program including, but not limited to, travel in automobiles, attendance at related group activities on or outside of church property general participation in any and all activities sponsored by or associated with Highland United Methodist Church. The parent or legal guardian also grants permission for the said child’s pictures to be taken at Youth Group and/or Highland United Methodist Church sponsored events on or outside of church property, which can be used on the church website (Highland United Methodist Church), social media accounts, and promotional materials.
*
Please select all that apply.
Yes
No
Medical Release and Information
This consent also includes specific permission hereby granted to the adult supervisors and leaders of Highland United Methodist Church’s Youth Program to make medical decisions with respect to the said minor child in the event of accident or injury when parental consent shall be unavailable or when circumstances shall require immediate medical decision, and to administer medication when required.
*
Please select all that apply.
Yes
Emergency Contact Name
*
Emergency Contact Phone
*
Insurance Company
*
Group Number
*
ID or Plan Number
*
Primary Care Physician
*
Medical Conditions or Allergies
*
I, do hereby verify that the above information is correct and I do hereby release and forever discharge all sponsors and Highland United Methodist Church from any and all claims, demands, actions or causes of action, past, present, or future arising out of any damage or injury while participating in a church-sponsored youth activity.
*
Please select all that apply.
Yes
Submit
Description
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