Youth Group Registration 2019-2020 Youth Group YearFill out the below information to register your youth for the 2019-2020 youth group year. Youth InformationYouth's Name* First Last Youth's Email Address Youth's Cell Phone NumberDate of Birth*mm/dd/yyyy Date Format: MM slash DD slash YYYY Grade*Youth's 2019-20 School GradeSELECT ONE6th7th8th9th10th11th12thPlanning to Participate in Youth Choir*SELECT ONENoYesParent InformationParent/Guardian Name* First Last Parent/Guardian Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Home Phoneif applicableParent/Guardian Cell Phone*Parent/Guardian Email Address* Emergency Contact InformationEmergency contact must be different than the parent/guardian listed above and will only be contacted if the parent/guardian cannot be reached.Emergency Contact Name* First Last Relationship to Youth*Emergency Contact Home Phoneif applicableEmergency Contact Cell Phone*Medical InformationInsurance Company*Insurance Company Phone*Policy #*Policy Holder's Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Employerif a group planDate of Most Recent Tetanus Shot Date Format: MM slash DD slash YYYY Physician's Name*Physician's Phone*Dentist's Name*Dentist's Phone*Current Medications & ScheduleKnown AllergiesSpecial Dietary NeedsI give my permission for WPC staff/volunteer youth advisors/chaperones to provide my child with over-the-counter medication (Advil, Tylenol, Benadryl, Dramamine, Pepto Bismal, etc.).*SELECT ONEYesNoPlease list any special or medical needs that we should be aware of.Check if your youth has a history with these medical conditions:(check all that apply) Asthma Bee Sting Reaction Blood Pressure Problems Cancer Convulsions Diabetes Fainting Food Allergies (check here and list above) Hay Fever Heart Disease Kidney Problems Lung Problems Sulpha Drug or Penicillin Allergic Reaction Ulcers Other Pertinent Medical HistoryPermission, Medical, and Liability Release Statement*By checking this box, you are confirming you have read and agree to the Permission, Medical, and Liability Release Statement. Yes CovenantPlease read with your youth and electronically sign (by checking yes) to signal that you will uphold the expectations listed below.*In line with our identities as children of God and disciples of Jesus Christ, we expect all youth to abide by the covenants they sign for particular youth trips. We expect all participants in our youth activities to uphold and promote the values of our church and youth group. We expect that everyone who participates in our trips and local activities (including weekly youth group) with us will represent Christ in their actions, language, and intentions. Inappropriate language, language that demeans others, and disrespectful actions do not have a place in the WPC Youth Group. We expect youth to obey the rules presented and the adults who lead them at weekly youth group. These rules may be in regard to the physical space of the church, use of cell phones, or behavior in general. We ask youth and adult advisors to treat God's house as your house and God's people as your family. We also expect all youth to treat the trips we go on as special opportunities for faith development and fellowship with our friends at church. This includes only bringing items that will enhance our time together. Please do not bring alcoholic beverages, tobacco products, vapes or electronic cigarettes, drugs (including prescriptions not in your name), or any material items (including clothing) with inappropriate language, connotations, or illustrations. Yes DON'T FORGET TO CHECK THIS BOX! This iframe contains the logic required to handle Ajax powered Gravity Forms.