Sponsored by the Presbyterian Church

Youth & Children’s Ministry

Participation Form

Sponsored by The Presbyterian Church

500 W. Main St., Danville, KY 40422

The information provided is for activities located at, and/or sponsored by, the PresbyterianChurch of Danville. Activities include, but are not limited to: Godly Play, Sunday Evening Fellowship, PYC Local & Non-local Mission Opportunities, Parents Night Out/Kids Night In, Playdates, Nursery care, and other Fellowship Opportunities. Additional registration or sign up may be required. Information will be kept in the children and youth classrooms and the main office.

Child’s Name / Birthdate
MM/DD/YYYY / Grade / T-shirt Size

Parent/Guardian Name: ______

Street Address:______

City:State:Zip:

Home Phone: ______Cell Phone: ______

Preferred email address:______

Home Church:

In case of emergency (if parent/guardian cannot be reached) please contact:

Name: ______

Telephone: ______Relationship ______

People authorized to pick up child at the end of activities:

Name(s):______

Phone Number(s): ______

Allergies or other medical conditions (indicate child):

Is activity sponsor authorized to approve medical treatment?YesNo

Is participant covered by personal/family medical insurance?YesNo

If yes, name of the insurer:

Policy or group number:

Participant Agreement:

By signing below, the parent/guardian acknowledges and accepts the risks of physical injury associated with participation in activities of the church.

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activity dates shown on this form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.

I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed.

I understand all reasonable safety precautions will be taken at all times by The Presbyterian Church of Danville and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold The Presbyterian Church of Danville, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

Parent/Guardian Signature: ______Date:

Photo Request:

The Presbyterian Church takes photographs of all sorts of church events. The church would like to share some of these pictures in places like the church website, Facebook, emails and promotional materials. If you would prefer that your picture or your child’s picture NOT be used, please write your initials in the space below.

I would prefer pictures of me or my child NOT be used in church promotional materials. ______