2024-2025 After School Registration and Permission Form

Child's Name

This address will receive a confirmation email

Phone

Address

Grade

Birthdate

School

Parent/Guardian name(s)

Parent/Guardian Cell Phone #

Secondary Emergency Contact Name and Phone Number

I, hereby give permission for my child to participate with the Rumple Memorial Presbyterian Church Youth and Children's ministry activities (both on and off the Rumple campus) from August 2023-July2024. This includes transportation in the car of an adult volunteer/staff.

Yes No

I, hereby release Rumple Memorial Presbyterian Church, its staff members, and volunteer leaders from any and all liability due to injury, loss, or damage to person or property that may occur during the course of the trip, including travel time in personal vehicles.

Yes No

In case of a medical emergency with my child and I cannot be reached, I give my permission to the adult leaders to permit hospital personnel and/or a licensed physician to perform emergency treatments and administer medicine in conjunction with such emergency treatment to my above-mentioned child.

Yes No

I have read and understand the above Assumption of Risk and Release (initial and date)

I give Rumple Memorial Presbyterian Church permission to use photographs and videos of my child/youth on their website, social media, and church publications. No child or youth will ever be identified by name on social media platforms. (initial)

Because of live streaming and our bulletins being available on our website, do we have permission to use your child/youth's first and last name in worship and in the bulletin?

Yes No

Please list any dietary restrictions and/or allergies

List any medications your child is currently taking

Please list any necessary medical history

Health insurance information: list company name, policy number and company phone number

Description

Please fill out this form and click submit.

2024-2025 After School Registration and Permission Form

Description

Please Fix the Following