Name: Tipping Media
Price range: $

Parent Name

Second Parent Name (if applicable)

Best Telephone Number

Parent Email

How many students are registering with the youth ministry?

First Student's Name

First Student's Birthdate

Year

Month

Day

First Student's Cell Phone (if applicable)

Second Student's Name

Second Student's Birthdate

Year

Month

Day

Second Student's Cell Phone (if applicable)

Third Student's Name

Third Student's Birthdate

Year

Month

Day

Third Student's Cell Phone (if applicable)

I/We give full consent to have my child receive first air by trained staff members or registered nurse, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. In case of an emergency, when I cannot be reached, I/We give consent for either of the emergency contact persons listed above or the church staff to act on my/our behalf to authorize the necessary medical treatment until I/We are available.

I/We give permission for The Church of St. John the Divine to use my/our child(ren's) name(s) and photos in promotional materials (publications, website or on the local news) and publicity regarding various activities of The Church of St. John the Divine. I hereby waive the right to inspect or approve finished photographs, or the use to which it may be put or the copy of illustrations used in connection therewith.

The Church of St. John the Divine requests that all personal items such as cell phones, video games, cameras, and other items be left at home. We will not be responsible for the replacement of items broken, lost or stolen.

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