Wesley | Youth Registration

Youth Registration Form

Student information

Add Additional Student

First Name

Last Name

School

Gender

Birthday

Grade

Guardian information

Add Additional Guardian

First Name

Last Name

Receive Updates

Address 1

Address 2

City

State

Zip

Primary Phone

Secondary Phone

Photography and Media Usage Consent

(I, We,) consent to Wesley taking and using photography and media of my child during events for promotional purposes. It is okay for this material to be posted on Wesley’s website, Facebook page, or other online or offline published accounts or promotional materials.

Transportation Permissions and Waiver

(I, We,) also give our child permission to ride in the church van to and from an event. I also understand that private drivers, which may include my child (pending my written permission below), a volunteer, or the parent of another student participating in the activity, may be used to transport students to and from the activity. The owner of the vehicle must carry bodily injury insurance. The Church’s insurance does not cover damages arising from, or related to, the operation of any private vehicle, failure to follow the directed driving route, or any personal negligence related to this activity. Any damages/harm resulting from a parent/guardian/or other designated driver (including student-drivers), arising from the operation of a motor vehicle in relation to the above listed activity, is hereby waived. I recognize participation in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify I have been advised of the potential risks, and I have full knowledge of the risks involved in this activity, and I assume any expenses incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. Please check to the left of each statement below to acknowledge your acceptance of the following permissions:

I give permission for my child to ride in a vehicle to and from the activity with another student.

I give permission for my child to transport students to and from the activity.

I give permission for my child to ride in a vehicle driven by Church staff, a volunteer, or parent of another student to the activity.

Medical Consent

(I, We,) hereby give permission for my child to participate in the Youth Group activities of Wesley Church, Quarryville. In the event that I cannot be reached in an emergency,(I, We,) the undersigned parents(s)/person having legal custody/legal guardian of student(s) specified above, a minor, do hereby authorize Wesley Church, Quarryville as agent for the undersigned to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act and/or the Dental Practice Act for my child. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgement, deem advisable. (I, We,) hereby authorize any hospital, which has provided treatment to the above-named minor to surrender physical custody of such minor to (my, our) above-named agent upon the completion of treatment. As parent or legal guardian of my child, I am responsible for the health care decisions of my child and am authorized to consent to the services to be rendered. I represent that my consent and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child is legally sufficient and that no consent from any other person is required by law.

Insurance Company

Policy Number

Special Medical Concerns

Agree to Terms

As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Wesley Church and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and authorization form, I fully understand its terms and conditions, and I agree to be legally bound by its terms. I also understand that I have the ability to refuse to sign this Form. In addition, that if I refuse to sign, my child will not be permitted to participate in the activity.

Please type your name to sign (must match a guardian name)

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