2023-24 Youth Ministry Registration

Youth Registration Information

Youth Name (first, middle, last)

Date of Birth

School Grade as of Fall 2023

Name of School

Youth Email

Youth Cell Phone Number

Okay to text youth?

Youth Mailing Address

Parent/Guardian 1 Name

Parent/Guardian 1 Address (if different from youth)

Parent/Guardian 1 Email

Parent/Guardian 1 Cell Phone

Parent/Guardian 1 Home Phone

If applicable, please complete info for an additional parent/guardian.

Parent/Guardian 2 Name

Parent/Guardian 2 Address (if different from above)

Parent/Guardian 2 Email

Parent/Guardian 2 Cell Phone

Medical Information

All youth who participate in our programs must have a completed current Master Medical Form prior to participating in any offsite event.

This form will be kept on file with the church for the program year 2023-2024. If any of the medical info changes within the year, please notify Sydney Harkrider at [email protected] .

Master Medical form 2023-24

CARE PROVIDER INFO

Name of Pediatrician/Family Physician

Physician's Phone #

Physician's Address

Insurance Carrier

Insurance Carrier Address

Insurance Carrier Phone #

Insurance Policy Number

Insurance Group Number

ALLERGIES and OTHER MEDICAL CONDITIONS

The following information must be filled in by the parent/guardian. The intent of this information is to provide our staff and volunteers with background to provide appropriate care. Any changes should be communicated with us as updates are necessary.

List all known allergies to food, medication, or other allergens. Describe reaction and management of the reaction. Also, please explain any medication conditions that staff should be aware of.

Allergies

Medical Conditions

MEDICAL CONSENT

I grant permission for my child/youth to receive any emergency medical treatment and/or transportation for medical/hospital treatment while participating in classes, worship activities, fellowship groups, camps, mission trips, retreats, and other programs with First United Methodist Church, 516 Church Street, Evanston IL 60201, 847-864-6181.

Participant's Name

Parent/Guardian Name

Date

Additional Information

Please share any info (for example, learning differences and preferences) that might help us effectively engage this youth.

Photo, Video, Podcast, Social Media Release

First United Methodist Church of Evanston, IL will use current and prior photographs and/or videos of and quotations from our youth in our print publications, website and social media pages. These photos, videos and quotations are never associated with the full name of the youth. Photos, videos, and quotes are used solely to promote and support our ministry.

Media Release

I/We agree with the above statement of release.
I/We DO NOT agree with the above statement of release.

Youth and Family Covenant Agreement

I agree that at youth group, on mission trips, at service projects, and at classes, I will: (1) respect other people; (2) respect the leaders, (3) respect church values, (4) respect the property, and (5) respect myself (i.e., I will not be under the influence of illegal drugs or alcohol).

I have read the Youth and Family Covenant and agree to abide by its principles.

Waiver and Release of Liability

I agree that First United Methodist Church Evanston, its staff and volunteers, will not be held responsible for accidents arising from my child's participation in on and offsite church activities. In the event that my child's parent/caregiver and/or emergency contact cannot be reached in case of an emergency, I hereby grant permission to the physician selected by the church to secure and administer treatment. I agree to indemnify and hold harmless First United Methodist Church Evanston, its staff and volunteers, against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf.

I/We agree with the above waiver and release of liability*

Electronic Submission Form

By clicking the submit button, I am hereby registering my youth for 2023-2024 programming activities at First United Methodist Church of Evanston.

I have read and agree to the terms above.

Almost done. Where should we send the confirmation?

Name

Event Registration Software by RegFox

2023-2024 YOUTH

PROGRAM REGISTRATION