Family Youth and Children's Ministry Participant Information Form

CONTACT INFORMATION

Child/Youth Information

Child/Youth Name

Date of Birth

Child/Youth School (name)

Child/Youth Grade for 2023-2024 academic year

Child/Youth Email

Child/Youth Cell Phone

Child/Youth Address

Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Cell Phone

Parent/Guardian Home Phone

Parent/Guardian Address

Additional Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Cell Phone

Parent/Guardian Home Phone

Parent/Guardian Address

Alternate Emergency Contact Information

In the event of an emergency, every effort will be made to contact parent/guardian(s). Please name an alternate contact in the event that parent/guardian(s) can not be reached:

Name

Relation to child/youth

Phone

MEDIA RELEASE

Images and recordings help us tell the story of Forest Hill Church and communicate our commitment to becoming the beloved community. Media images enhance the quality of information we provide to members, visitors, and the community about our worship, programming and activities.

Please indicate your permission below for the image/photo/video of the child/youth named above to be used in church-related materials, including but not limited to, bulletins, posters, brochures, newsletters and other printed materials and on the church's website and social media platforms.

Permission granted:

Yes No

MEDICAL/HEALTH INFORMATION

Please indicate any medical/health information that adults should be aware of or sensitive to when planning and and leading programming activities and events.

Physical/Medical concerns (e.g. allergies, asthma, diabetes))

Behavioral/Mental Health concerns

Medications that may be carried/taken during programming/events (e.g. Epi-Pen)

Doctor/Hospital Info

Name of Child's/Youth's Doctor

Doctor's Phone

Preferred Hospital

Medical Insurance Information

Name of Medical Insurance Company

Policy Number

Insured Member's Name

LIABILITY RELEASE / CONSENT FOR TREATMENT

I hereby release Forest Hill Church, Presbyterian (FHC), its staff and adult representatives from responsibility and liability for any injury or illness that my child/youth may sustain during programming activities and events sponsored by the church.

In the event of an emergency, FHC staff and adult representatives will make every effort to contact me, or the alternate persons named, as soon as possible. I authorize FHC staff and adult representatives to seek medical treatment for my child/youth. I give my consent to examination, diagnosis, treatment and/or care of my child/youth by a certified provider in a physican's office, emergency room or hospital.

PLEASE TYPE YOUR FULL NAME BELOW AND SUBMIT TO SIGN.

You acknowledge that all information submitted on this form will apply to FHC sponsored programming activities and events through the 2022-23 program year (Oct 2022-Aug 2023)

Please notify Amy Wheatley, ce@fhcpresb.org of any significant changes in contact information, medical information or health concerns.

Full Name of Parent/Guardian Completing this Form

Description

Please fill out this form and click submit.

The information you provide will be treated confidentially and is used only for purposes of church-related communication and the health and safety of your child/youth when participating in church programming..

Family Youth and Children's Ministry Participant Information Form

Description

Please Fix the Following