2026-27 Youth Group Registration
Please fill out this form and click submit.
Parent/Guardian Information
Parent/Guardian 1
Name of Parent/Guardian 1
*
Address
*
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Email
*
This address will receive a confirmation email
Phone
*
You have my permission to text me.
*
Please select all that apply.
yes
No
Parent/Guardian 2
Name of Parent/Guardian 2
Address (If different from Parent/Guardian 1)
Email
This address will receive a confirmation email
Phone
You have my permission to text me.
Please select all that apply.
Yes
No
Please include Parent/Guardian 2 in weekly youth group communication.
Please select all that apply.
Yes
Youth Information
Youth 1
Youth's Name
*
Youth's Grade for 26/27 School Year
*
Date of Birth
*
t-shirt size
*
Email
*
Phone
*
You have my permission to text my youth.
*
Please select all that apply.
Yes
No
List any food, drug, or other allergies. Note if epi-pen is carried.
Youth 2
Youth's Name
Youth's Grade for 26/27 School Year
Date of Birth
t-shirt size
Email
Phone
You have my permission to text my youth.
Please select all that apply.
Yes
No
List any food, drug, or other allergies. Note if epi-pen is carried.
Youth 3
Youth's Name
Youth's Grade for 26/27 School Year
Date of Birth
t-shirt size
Email
Phone
You have my permission to text my youth.
Please select all that apply.
Yes
No
List any food, drug, or other allergies. Note if epi-pen is carried.
Emergency Contact and Medical Information
In the event of an emergency, all efforts will be made to contact the parent/guardian of the child. In the event the parent/guardian cannot be contacted, the following person will be contacted.
Name of Non-Parent/Guardian Emergency Contact
*
Relationship to Youth
*
Phone number of Non-Parent/Guardian Emergency Contact
*
Consent
Please provide your electronic signature to indicate your agreement with the following statements.
Covenant & Participation
I understand that my youth is expected to be respectful and kind during Polk City United Methodist Church youth activities and to uphold the covenant we will create together about how we treat one another. These shared promises will guide how we behave and support one another, and each youth is expected to honor them. Failure to consistently meet these expectations could result in removal from youth group and/or the mission trip roster. Participation in our two primary fundraisers, as well as regular attendance at youth activities throughout the year, is required for participation in the the 2027 Youth Mission Trip. (Type electronic signature indicating agreement.)
*
Parent/Guardian Consent
I have legal custody of the student(s) named, a minor, and am giving my consent for him/her to attend events organized by Polk City UMC. I understand there are risks involved in any event and I hereby release Polk City UMC, its pastor, employees, and volunteers from any and all liability for any injury, loss, or damage to a person or property during the course of my child's involvement with the organization. (Type electronic signature indicating agreement.)
*
Medical Consent
In the event my child is injured and requires medical attention, I hereby give consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event that treatment is required from licensed physician or hospital personnel, I agree to hold such person free and harmless of any claims of responsibility for the cost of any medical care not reimbursed by my insurance provider. (Type electronic signature indicating agreement.)
*
Photo Release
Occasionally the church takes photos and videos during events for use on official church social media account, newsletters, and/or website. Please check the box indicating your consent to have your child's photo posted on these official platforms only.
*
Please select one option.
Yes
No
Submit
Description
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