Youth Ministry Participant Form

Basic Information
Student's Name*
First Last
Student's Cell*
Student's Email*
School*
Grade*
Birthday*
MM slash DD slash YYYY

mm/dd/yyyy
Age*
Family Information
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Family Email
Parent 1*
First Last
Parent 1 Cell
Parent 1 Email
Parent 2*
First Last
Parent 2 Cell
Parent 2 Email
Communication
One of the primary ways we provide information and inform you of upcoming events and schedule changes is through texting. We also frequently use emails, the website and our Hiland FaceBook page. In the fields below, please indicate which cell(s) and which email(s) you would prefer we use for communication. At least one cell and one Email is required.
Cell*
Cell
Cell
Email*
Email
Email
Photo Release
Your permission is required for photographs of the student listed above to be published on the website of Hiland Presbyterian Church, in Hiland printed publications, and audio/video presentations of Hiland youth group activities for publicity purposes. I understand that these photos can be viewed by anyone in the world, but no identifying information will be displayed.
I give my permission*

Yes

No
Name of person giving permission (The student may give permission if he/she is at least 18 years old)
First Last
Permission for Youth Ministry Trips and Events
My child (named above) may take part in field trips, retreats, mission trips, or any other excursions under appropriate supervision of a representative of Hiland Presbyterian Church.
I give my permission*

Yes

No
Name of parent giving permission*
First Last
Home phone
Work phone
Cell phone
Home Address*
Street Address Address Line 2 City City ZIP Code
Medical History and Insurance Information
Physician's Name*
Physician's Phone*
Allergies*

If the student has no allergies, please enter "none"
Physical Restrictions*

If the student has no physical restrictions, please enter "none"
List of current medications and dosages*
If student is not currently on any medications, please enter "none"
Dietary Restrictions*

ie: vegetarian, lactose intolerant, etc. If student has no dietary restrictions, please enter "none"
Student's Date of Birth*
MM slash DD slash YYYY

mm/dd/yyyy
Date of last tetanus shot*
MM slash DD slash YYYY

mm/dd/yyyy
Social Security #*
Name of Emergency Contact*
First Last
Emergency Contact Phone*
Insurance Company*
Member ID and Group #*
Authorization for Emergency Medical Treatment and Liability Release
I hereby authorize a representative of Hiland Presbyterian Church to give consent for the medical treatment of my child in the event of illness or injury. I further release Hiland Presbyterian Church, its employees, and its volunteers from any liability in the event of any accident en route, during, or returning from any church events and/or trips. In case of emergency, I understand that every effort will be made to contact me as a parent or guardian. In the event that I cannot be reached, I hereby give permission to the physician or medical professional selected by the church representative to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as needed.
Name of authorizing parent*
First Last
Today's Date*
MM slash DD slash YYYY

mm/dd/yyyy

Youth Ministry Participant Form

Basic Information

Family Information

Communication

Photo Release

Permission for Youth Ministry Trips and Events

Medical History and Insurance Information

Authorization for Emergency Medical Treatment and Liability Release