Youth Registration & Medical Consent Form for 2023-2024 School Year

Student Information

Student First Name *

Student Last Name *

Preferred Name *

Gender *

Home Address *

Home City *

Home State *

Home State (Not OH) *

Home Zip Code *

Student Phone Number *

Student Email Address

Date of Birth *

Parent/Guardian Information

Primary Parent/Guardian Information:

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Mobile Number *

Parent/Guardian Email Address *

Additional Parent/Guardian Information (Optional):

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Mobile Number

Parent/Guardian Email Address

Emergency Contact

Please provide us with the name and phone number of someone who is not a parent or guardian of this student that we can contact in the case of an emergency:

Emergency Contact First & Last Name *

Phone *

Communication

Youth ministry is based on building authentic relationships that lead to conversations about Jesus. It's our desire to have open communication with students who participate in youth ministry. We will do so following our Safe Place Policy. We also want to be in touch with you, the parent/guardian, so we can support you in investing in the spiritual life of your student.

Contact: I give permission for Stow Alliance staff or volunteers to contact my child via the following: *

Photos: I give permission for Stow Alliance to use photos including my student in the following publications: *

Medical Information

Information received is confidential and is being gathered for the purpose of serving your child while in the care of Stow Alliance. Any medical information collected here serves to authorize Stow Alliance's staff and volunteers, to obtain medical assistance in emergencies.

Insurance Company Name and Policy Number *

Physician *

Physician Phone Number *

Dentist *

Dentist Phone Number *

Allergies (medicine, food, other) *

Does your child have any physical, emotional, mental, behavioral concerns or limitations that our staff should be aware of? *

Please explain: *

Does your child use any medications that they would need to use during any event (including overnight events)? *

Please list and include times taken: *

Consent

While every precaution is taken for safety and good health, some sports & activities carry with them the inherent risk of personal injury beyond the risks associated with many of the recreational activities at the church. I understand & accept these risks and agree that by allowing my child to participate in those activities, he/she may be taking part in a recreational activity that presents the potential for personal injury.

I, the above named parent/guardian, consent to the participation of my child in all supervised activities on and off Stow Alliance property. *

I Accept

I, the above named parent/guardian, authorize Stow Alliance ministry staff and volunteers to sign consent for medical treatment, to authorize any physician/hospital to provide medical assessment, treatment, procedures for the participant named above. *

I Accept

I, the above named parent/guardian, undertake and agree to indemnify and hold blameless Stow Alliance, its pastors, representatives, & board of elders from and against any loss, damage, injury suffered by the participant as a result of being part of the activities of Stow Alliance. *

I Accept

By adding your name below, you confirm that you have read, that you understand and that you give consent to all of the previous information required on this form:

Parent/Guardian Name *

Date *

Purpose and Extent:

Stow Alliance is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our church. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel. If you would like for Stow Alliance to limit the information collected, or to view your child's information, please contact us.