NEXT GEN Youth Group Registration for 2024/25

Student Information

Student's Name

Phone

Address

Gender

Male Female

Birthdate

Current Grade

6th 7th 8th 9th 10th 11th 12th

School

Coatesville Octorara Pequea Homeschool Cyber School Twin Valley Other

T-Shirt Size Child small Child medium Child large Child XL Adult small Adult medium Adult large Adult XL Adult XXL

Parent/guardian Information

Parent First

Parent Last

Parent Email

This address will receive a confirmation email

Parent Home Phone

Parent Mobile

Relationship to child

Name of emergency contact

Phone for emergency contact

Email for emergency contact

Relationship to child

Name of secondary emergency contact

Phone for secondary emergency contact

Email for secondary emergency contact

Relationship to child

Medical/Insurance

Does your child have any medical/physical conditions including food/drug allergies we should know about?

Special Instructions/medications

Date of last tetanus shot or booster

I do not wish my child to participate in the following:

Health Insurance Company

Health Insurance Policy Number

Policy Holder Name

Policy Holder Phone #

Primary Care Doctor

Primary Care Doctor Phone #

Preferred Hospital

Other Info

Are you actively involved in a local church? yes no

Name of Home Church

How did you hear about Next Gen? At IMPACT Friend Website Mailing Other

Student security

I do not have any specific security concerns I want to specify who may pick up my student I want to specify who may NOT pick up my student

Names for above concerns

Permissions and Signature

I give my permission for my student(s) to attend and participate in the 2024/2025 NEXT GEN Youth Group program sponsored by Impact Church.

Yes

I understand that I must sign a printed consent form before my student(s) may participate in any activities or field trips for NEXT GEN Youth Group.

Yes

I understand that in the event that my student(s) is in need of medical attention and I cannot be reached, IMPACT Church will obtain such medical treatment as deemed necessary.

Yes

I agree that any photographs or video taken of my student(s) while attending IMPACT Church events are the property of IMPACT Church and may be used in future publications.

Yes No

Name as signature

Date

NEXT GEN Youth Group Registration for 2024/25

Description

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