Gender
Select… Male Female
Grade
Select… Pre-K Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Parent/Guardian 1 *
What is your full name?
Please share anything important for us to know regarding the living arrangements or custody circumstances for this student. (optional)
Parent/Guardian 2
What is your full name?
Secondary Emergency Contacts *
In the event of an emergency, every attempt will be made to contact parents/guardians listed above first. Please provide at least one additional emergency contact, in the even that a parent/guardian cannot be reached. Please list the full names, phone numbers, and relationship to your student of each contact. Example:
Is Central authorized to approve medical treatment? *
Is student covered by personal/family medical insurance? *
Medical Notes
Any allergies, medical conditions, or anything we should know? No snacks offered will contain peanuts.
Sunday and Homework Help/Youth Group Transportation *
Please check all that apply.
Media Release for Minors *
By completing this electronic form, you grant permission for any image, photo, or video of those minors named to be used by Central for church-produced materials including, but not limited to, bulletins, posters, brochures, newsletters, other printed materials, social media and on the church website. No identifying information will accompany photos including names of minors, addresses, email addresses or schools. Social media photos will not be posted during events to prevent the location of children being made public. You may request at any time to have a particular media item removed by contacting the church office.
Select… By completing this form electronically, I/we grant permission for the image, photo, or video of any minors named on this form to be used by Central as described above. I object to the release or use of any media images or recordings that will be produced, used, or distributed by Central for church purposes.
Participation Agreement *
By completing this form electronically, I acknowledge that participation in TeenCentral involves risk to the participants (and to the participant's parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infections/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for my children's opportunity to participate in the programs, I acknowledge and accept the risks of injury associated with participation in and transportation to and from the activity. I accept personal financial responsibility for any injury or other loss sustained during the programs or during transportation to and from the programs, as well as for any medical treatment rendered to the participant(s) that is authorized by Central or its agents, employees, volunteers, or any other representatives (collectively referred to as the "program sponsor"). Further, I release and promise to indemnify, defend, and hold harmless the program sponsor for any injury arising directly or indirectly out of the programs or transportation to and from the programs, whether such injury arises out of the negligence of the program sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, I agree to resolve the matter through a mutually acceptable alternative dispute resolution process. If I and the program sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.
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