Student Information Form

June 1 | West Salem FCC

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Please complete one form per student. You should only have to complete this form one time for all future events. Thank you for your cooperation.

Student First Name *

Student Last Name *

Address 1 *

City *

Zip / Post Code

Parent Name

Parent Phone Number

Emergency contact if parent cannot be reached, and the relationship to the student. *

Emergency contact phone number if a parent cannot be reached. *

Student Phone Number

Student Birthdate *

Please list any allergies or medical conditions the student has. *

Is there anyone not allowed to have contact with the student?

Do you have a home church? If so, please list.

First Christian Church has a website and social media pages where photos and videos from Youth Group events are periodically published. It is First Christian Church’s policy that photos of children are never published with names or other identifying information. May we use photos of your child in our publications? *

“I/We hereby grant permission for my/our child listed above to be a member of the Youth Group at First Christian Church and to participate in activities arranged by the Youth Leadership in this regard from time to time. We recognize the importance of the commitment that he/she makes and that their participation as a part of a larger community calls for responsible behavior. Therefore, I/we agree that if this child engages in behavior which, in the judgment of the adult leaders, is not in the best interest of the trip or event, our/my child or any member of the group may, therefore, be sent home. I/We will assume full legal and financial responsibilities for such a return trip.” “I/We hereby release from any liability First Christian Church and all of its personnel, employees, adult leaders and representatives from any claims for unintended or unexpected accidents which might occur during participation in youth group events or traveling to or from said events. In granting this permission and release, I/We specifically recognize that my child may from time to time be transported to events by private vehicles operated by advisors or volunteers not as agents, employees or representatives. In such regard, I/We specifically release and will hold harmless First Christian Church, their officers, employees, agents and representatives from any and all liability which may arise as a result of such transportation whether or not organized by First Christian Church.” If you agree to the above statement as the adult over the student please place your name in the box below. This will act as your signature. *