Youth Alive Registration | Living Word Christian Church

Youth Information

Youth Name(Required)

First Middle Last

Nickname

Birthday(Required)

Gender(Required)

Male

Female

Grade

This program runs September 1 - August 31. Even if your youth has completed a grade in school, in this program they are still considered to be in that grade through August 31.

Address(Required)

Street Address Address Line 2 City State ZIP Code

Youth Email

Parent Information

Parent Name(Required)

First Last

Home Phone(Required)

Cell Phone

Email(Required)

Parent Name

First Last

Home Phone

Cell Phone

Primary Contact Information

Complete this section ONLY if you are the primary contact for the youth, but are not the parent (grandparent, guardian, caretaker, etc.). If you are not the official guardian, also complete the Parent Information.

Contact Name

First Last

Home Phone

Cell Phone

Relationship to Youth

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact Information

Name

First Last

Phone

Relationship to Youth

Custodial Information

Is there any custodial information that we should be aware of?

Yes

If yes, please explain:

Church Information

Do you have a home church?

Yes

If yes, where:

Special Information

Youth Interests, Sports, Hobbies:

School Sports or Activities you would like us to be aware of:

Social Accounts Used:

General Permission

I hereby give permission for this youth to participate in events and activities hosted by Living Word Christian Church and receive oversight from the authorized staff in charge, whose care the youth has been entrusted into while attending and participating in these events and activities. (Note that all staff must be a member of Living Word Christian Church and must comply with a background check and any/all restrictions thereof.)

Initial

Consumption Permission

I hereby give permission to Living Word Christian Church for this youth to be offered snacks by authorized staff while in attendance.

Initial

Photo/Video Permission

I hereby give permission to Living Word Christian Church to record pictures or videos of this youth while in attendance. I give permission to Living Word Christian Church to use these pictures or videos in church publications including, but not limited to, print publications, slideshows, church website, church social networks, etc. knowing that the youth's identity is kept anonymous.

Initial

Travel Permission

I hereby give permission to Living Word Christian Church for this youth to ride in a vehicle designated by authorized staff, for the purpose of transportation to and from events and activities hosted by Living Word Christian Church. (Note that all drivers must be at least 21 years of age and produce a valid driver's license and proof of insurance.). This permission does not include personal transportation, only that as part of the activity.

Initial

Medical Information & Permission

Please note all applicable allergies, medical conditions, mental conditions, health history, or medication information that would be necessary in an emergency:

Medical Condition(s):

Medication(s) / Dosage:

Allergies (Food / Drug):

Physician(s):

Hospital:

Date of last physical exam:

Date of last tetanus shot:

General health for the past two years:

Excellent

Fair

Poor

Special Notes or Instructions:

Initial

Release From Liability

I hereby hold harmless Living Word Christian Church, aka Word of Life Ministries, Inc., and any of its employees, staff, members, and/or volunteers of any liability incurred at or as a result of attending events and activities hosted by Living Word Christian Church.

Initial

If emergency or required medical care is needed, I hereby give permission to Living Word Christian Church to such medical care as deemed necessary by medical care providers or the authorized staff.

Parent/Guardian Printed Name

Completed

I confirm that I have completed this form on the date listed.

Date