Event Registration and Permission Forms

Annual Permission Form

This form should be filled out once a year for each child/youth.

Annual Permission Form for September 1, 2024 - August 31, 2025

Orrstown United Brethren Church - Annual Permission Form -Effective Dates: September 1, 2024 - August 31, 2025

Child/Youth Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Age(Required)

Grade(Required)

Gender

Child/Youth Email

Enter Email Confirm Email

Parent/Guardian Email(Required)

Enter Email Confirm Email

Child/Youth Cell Phone

Home Phone

Mother's Name

First Last

Mother's Cell Phone

Father's Name

First Last

Father's Cell Phone

Additional Emergency Contact

First Last

Emergency Contact Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child/Youth's Physician

Physician's Phone Number

Medical Insurance Company

Policy Number

Medical History

For the safety of your child/youth, and for our knowledge to be able to keep them safe, please fill out the below information to the best of your ability.

Please rate your child/youth's ability to swim, in the event we go somewhere with a body of water.

Does your child/youth wear:

glasses

contacts

none of the above

Does your child/youth have any allergies? If so, is there any medication or procedures that need to be followed.

Does your child/youth suffer from, or ever experienced, or is currently being treated for any health related conditions? Please list them below with the freguency, treatment, or any other information the we should be made aware of to ensure your child/youth's well-being.

What was the date of the child/youth's last tetanus shot?

MM slash DD slash YYYY

Please list and explain any major illnesses the child/youth has experienced that could impact their ability to participate in any activities.

Should your child/youth's activities be restricted for any reason?

What over-the-counter medications are okay for us to administer to your child/youth? (Tylenol, Motrin, Advil, etc.)

Please list any medications your child/youth is taking, with the name, dosage, times per day, etc.

If not noted above, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which you child/youth is subject and of which the staff should be aware, and what, if any, action of protection is required on account thereof. Submit this information in the box below. Include names of medication, dosages, and frequency at which they must be taken.

Activities may include, but are not limited to cookouts, boating, water activities, swimming, basketball, roller skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, snow tubing, hiking, biking, concerts, Bible studies, golfing, hayrides, go-carts, and transportation to and from church activities and all events sponsored by the Leaders. Note: If you desire to limit your child/youth’s participation in any particular event, please submit your instructions below or in writing to the leader prior to that event.

Child/Youth Consent to Adhere to the Below Behavioral Policy(Required)

I, the child/youth named above, agree to the behavioral policy.

For your information, we expect each child/youth to conform to these rules of conduct during all activities:
• No possession or use of alcohol, drugs, or tobacco
• No child/youth will drive vehicles (except go-carts) during the activity (without written consent of the parent/guardian)
• No fighting, weapons, fireworks, lighters, or explosives
• No offensive or immodest clothing or dress
• No boys in the girls’ sleeping quarters and no girls in the boys’ sleeping quarters
• Participation with the group in all aspects of the event is expected
• Respect the property and privacy of others
• Respect one another, staff, and adult leaders
• Respect and comply with event schedules
• Children/youth who fail to comply with these expectations may be sent home at their parents’ expense.

I, the child/youth, have read the rules of conduct, the above evaluation of my health, and permission to participate in the group activities. I agree to abide by the stated personal limitations and rules of conduct.

Parent Permission(Required)

I, the parent/guardian, agree to the consent as written below

I/We, the undersigned, are the parents of and/or have legal custody of the child/youth named above, a minor, and have given my/our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, volunteers, and drivers of any vehicle transporting named child/youth, on a supervised outing, of any liability against personal losses of the named child. In the event that he/she is injured or becomes ill and requires the attention of emergency medical personnel or of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that I/we will ultimately be responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Furthermore, I/we affirm that the health insurance information provided above is accurate as of this date and will, to the best of my/our knowledge, still be in force for the child/youth named above. I/we also agree to bring my/our child/youth home at my/our expense should they become ill or if deemed necessary by the leader or staff member.

Photo Permissions(Required)

We occasionally take pictures during our events. We may use these pictures on our website, social media, or in presentations and slide shows within the church. Please let us know how you would like us to handle the pictures your child/youth is in.

Event Registration and Permission Forms

Annual Permission Form

Orrstown United Brethren Church - Annual Permission Form -Effective Dates: September 1, 2024 - August 31, 2025

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