Children & Youth Registration 12/29/21

Children/Youth Registration

Children's and Youth Ministry of Bethany Presbyterian Church
Check all programs for which you are registering. *

Godly Play New Thursday Children's Program Bethany Kids Toddler/Nursery Care Bethany Youth Group
Family Information
Parent Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Children/Youth
First Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
2021-2022 Grade
Medical or other information we may need to know about the child (including food allergies).
If child/children may be picked up by someone other than parent/guardian listed above, please explain
Second Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
2021-2022 Grade
Medical or other information we may need to know about the child (including food allergies).
If child/children may be picked up by someone other than parent/guardian listed above, please explain
Third Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
2021-2022 Grade
Medical or other information we may need to know about the child (including food allergies).
If child/children may be picked up by someone other than parent/guardian listed above, please explain
Fourth Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
2021-2022 Grade
Medical or other information we may need to know about the child (including food allergies).
If child/children may be picked up by someone other than parent/guardian listed above, please explain
Emergency Contact Information
Parent/Legal Guardian/Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Emergency Contact 2 (other than parent/guardian listed above)

First Name Last Name
Emergency Contact 2 Phone Number

Area Code Phone Number
Media, Participation, and Medical Releases
By clicking the box below, I hereby Give Permission for photographs and/or video in which my child appears in to be used by the church in printed and/or electronic media, including the church's website and social media. *

I Agree I do not agree
I hereby release Bethany Presbyterian Church (BPC) and it’s designated leaders from any liability for injury that my child(ren) may sustain participating in the Children and Youth activities at BPC. In case of illness or injury, and in the event I am unable to be reached or respond, I authorize Rev. Joanna Dunn, Trevor Walters, or BPC designated adult leaders to allow for emergency medical treatment by a licensed physician or hospital. *

I Agree
Electronic Signature - Printed *
Bethany Presbyterian Church requires that you certify your registration by submitting electronic signature acknowledging the release from the liability statement above. To certify, please provide an electronic signature (type your name). I certify all the above information in this registration is accurate and true.
Electronic Signature (Use finger, mouse, or stylus) *

Clear
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Children/Youth Registration

Family Information

Children/Youth

Emergency Contact Information

Media, Participation, and Medical Releases