St. Michael’s Episcopal Church
Youth Ministries
Living In Faith Together (LIFT)

Registration Form for Youth Events and Participant Info 2023-2024

Participant Name (please print)*

Gender*

Date of Birth*

School Name (for 2022–2023)*

Grade in School*

Youth Cell Phone No.*

Is it okay for youth leaders to text your teen directly?

Yes

Youth Email*

Address*

City, State, Zip*

Parent/Guardian Name*

Home Phone No.*

Parent/Guardian Cell Phone No.*

Parent/Guardian Email*

Parish/Church (if other than St. Michael's)

Static Content

Health Insurance Company*

Policy No.*

Insured's Name*

Youth Relationship to Insured*

Family Physician*

Physician Phone (Daytime)*

Physician Phone (After Hours)*

Static Content

Emergency Contact (other than above parent/guardian)

Name (please print)*

Relationship*

Home Phone*

Work Phone*

Cell Phone*

Name (please print)

Relationship

Home Phone

Work Phone

Cell Phone

Static Content

Special Medical Concerns (that might limit participation or be important in an emergency)*

Dietary Restrictions

Vegetarian

Yes

Allergies

The following is a list of medications youth participant will/may need to take while attending events (please attached list if additional room is needed)

Medication to be administered

Dosage

Times

Medication to be administered

Dosage

Times

Medication to be administered

Dosage

Times

All prescription medication must be properly labeled in its original pharmacy container.
Over the counter medication should be labeled with participant name on container.

Permission to receive OTC medications:

I give my permission for my child to receive over the counter medications from adult leadership at events, such as Tylenol, ibuprofen, cough drops, Mylanta, etc.

Parent/Guardian Signature*

Date*

Parent/Guardian Authorization for Health Care:

This health history is correct, and the person described has permission to participate in all activities except as noted by me and/or an examining physician. I give permission, to the provider, selected by the church, to order x-rays, routine tests, and treatment related to the health of my child in emergency/urgent situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with youth leadership.

Parent/Guardian Signature*

Date*

Photo/Video Publicity Release Statement:

I give my permission for photographs or video footage of my child to be used by St. Michael’s Episcopal Church for promotional purposes (Brochures, website photos, promotional videos, social media, etc.) No names are used for promotional photos/videos

Yes

Parental Consent:

I give full permission for my child to attend St. Michael’s youth events, including but not limited to: Bible Study, Starbucks social gatherings, Middle School/High School Retreats/Lock-ins, Mission Trips, and other events.

Transportation Release:

I give full permission for my child to be transported to youth activities in conjunction with the above mentioned events, away from our meeting site, riding in approved vehicles, with approved drivers from St. Michael’s and to attend and participate in activities off site.

Waiver of Liability:

I agree to hold St. Michael’s Episcopal Church and any associated agencies and persons free and waive any claims for payment for accident, injury, disability, or damages to the person or property of the aforementioned child arising out of or connected with his/her participation in any activity related to his/her participation in the aforementioned activities.

Parent/Guardian Signature*

Date*