Youth Ministry Registration Form

Please fill in all your family information. Both Spouses and all youth/ family members in your household.

Your name *

Email address *

Household members

Phone number *

Address *

Emergency Contact Info (Name & Phone number) *

Medical note - Does your youth have any physical, emotional, or behavioral concerns that our staff should be aware of? *

Yes

Does your youth have any allergies? (Please give full details if so. How would you like us to handle these in an emergency? Outline below.)

Family Doctor & Contact Info *

Care Card Number *

I understand that photos and videos may be taken throughout our ministries. Please indicate via check box to grant permission for the reasonable use of pictures containing your youth.

By checking the box you grant permission.

I understand that during Youth Nights at the church that games, activities, and snacks will all be a part of the night. I consent for my youth to be involved in these nights. *

By checking the box you grant permission.

I understand that as a part of registration with PCCC Youth, that there will be offsite events where my youth will possibly need to ride in a car and participate in riskier events away from the church. Those permission slips will be sent home prior. *

By checking the box you grant permission.

As the parent/ guardian do you acknowledge that this information is correct and that you are registering your youth for ministries at Powers Creek Community Church? *

Click check box in lieu of signature.

Digital Acknowledgment *

I have read, understood and agree with above and sign it to cover all Youth Program activities for the program year effective as stated above. I undertake and agree to indemnify and hold harmless Ministry Personnel, PCCC and its Leaders from and against any loss, damage or injury suffered by the participant as a result of being part of activities of PCCC, as well as any medical treatments authorized by the supervising individuals representing Powers Creek Community Church.