Youth Group Registration Form | Pitman Church of the Nazarene

Pitman Nazarene Youth L.I.O.N.S. Registration form.

All information will be kept strictly confidential. Information will only be used to serve your child in the context of youth ministry programming.

Student's First and Last Name (Required)

Parent / Guardian's First and Last Name (Required)

Home Phone Number (Required)

If not applicable to your family please put N/A

Parent / Guardian's Mobile Phone (Required)

If not applicable to your family please put N/A

Parent / Guardian's email address (Required)

If not applicable to your family please put N/A

Student's Mobile Number (Required)

This may be used to add your student to a group text, or to connect them to the Remind app which we use to send out information and reminders.

Home Address (Required)

Preferred Contact Method (Required)

Mobile Phone (Call)

Mobile Phone (Text)

Home Phone

Student's Date of Birth (Required)

Current Age (Required)

Current School Grade (Required)

Please list any allergies or medical conditions that it may be necessary for group leaders to know. (Required)

T-Shirt Size (Required)

Child - Small

Child - Medium

Child - Large

Adult - Small

Adult - Medium

Adult - Large

Adult - XL

Adult - XXL

Do you give permission for pictures / videos to be taken of your child? (Required)

Emergency Contact Information (Required)

(Please list the name, relationship to the child,,

Who has permission to pick up your child? (Required)

Please list names of those who have permission to pick your child up.

Does your child have permission to walk home from youth group?

Please note: If a child has permission to walk home they will no longer be under the church's supervision or responsibility once they leave the property.

No. My child should remain with the youth group until picked up.

Yes. My child has permission to walk home from youth group. Please contact us when they leave.

Sometimes. Please contact me first to see whether my child can walk home.

First Aid Permission (Required)

I (Parent/Guardian) of (the child listed above), authorize the leadership of Pitman Church of the Nazarene to care for the administration of first-aid for any minor injuries my child may receive while taking part in their youth programing. If any injury sustained causes need for emergency treatment, I authorize the leadership of Pitman Church of the Nazarene to summon emergency personnel to attend, transport, and treat my child. I agree to hold harmless any staff, assistants, and volunteer workers of Pitman Church of the Nazarene from any and all claims, suits, costs, and actions of any kind whatsoever, arising from their exercise of the power granted by this authorization. Entering my name in this text field indicates my agreement. Note: All Information on this form will remain confidential

Do you have any comments or concerns you feel the pastoral staff should know? (Required)

Pitman Church of the Nazarene

227 N Broadway (Street Address) P.O. Box 2 (Mailing Address)
Pitman, NJ 08071

(856) 244-8071

PitmanNaz@gmail.com

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