2017 Youth Volunteer for the 2017 MS Camp

Please complete one registration for each Youth Volunteer. To be filled out with/by parent/guardian.


Youth's First Name*:

Youth's Last Name*:

Gender*:

Birthdate mm/dd/yyyy*:

Age*:

Grade Entering*:

t-shirt size:


Food or Medical Allergies:
leave blank if none

Medical Concerns:
leave blank if none

Are you able to be a leader for the entire week (Monday - Friday) yes no

If not, what days/times will you be gone? What for?
leave blank if none


Parent/Guardian Information

Parent/Guardian First Name*:

Parent/Guardian Last Name*:

Cell Phone (###-###-####)*:
select primary cell

Cell Phone (###-###-####)*:
select secondary cell

Home Phone (###-###-####):

Parent/Guardian Email*:

Address*:

City*:

State*:

Zip*:


Emergency Contact Information

Emergency Contact Name*:

Relationship*:

Phone (###-###-####)*:


*PHOTO/VIDEO RELEASE
For privacy and safety, we will not publish names with photographs/videos.
I authorize the use/release of photographs and/or videos that include the INDIVIDUALS NAMED ABOVE for UCUMC use, in print and electronic materials (worship videos, e-mail blasts, church website, Facebook, etc.).

Photo/Video Release Given
Photo/Video Release Denied


Will you be needing Bright Futures hours? yes no

*RELEASE: Submitting this on-line form will be the equivalent of signing a paper registration form.
Yes, I agree

Name of Adult filling out this form*:

Date Electronically Signed mm/dd/yyyy*:



 
Please enter the text from the image in the box