Youth Registration Form

Your name *

Email address *

Address

Gender

Phone number *

Birthdate *

Grade

Medical note

Please describe any medical conditions or concerns we should be aware of

Household members

Add Additional Students

Parent Info

First Name *

Last Name *

Relationship to Youth *

Parent/Guardian

Extended Family (sibling, grandparent, aunt, uncle)

Step-parent

Family friend

Are you part of Clearview Community Church? *

Member

Regular Attendee

Visitor

Pease Read the Following Statements *

I, the undersigned, acknowledge and understand that all information collected, is for the sole purpose of Clearview Community Church and will not be shared by other parties.

I, the undersigned, acknowledge and understand that by entering the premises of the Clearview Community Church, consent to my child(ren)’s voice and likeness being videotaped and used without compensation for use in any format or media channel now known, or hereafter devised as the Clearview Community Church sees fit. You further release Clearview Community Church and its assignees, licensees, directors, officers, employees, agents and contractors from any liability on account of such usage.

I, the undersigned, acknowledge and understand that in the case of an emergency that every effort will be made to contact parents or guardians immediately. However, if parents or guardians cannot be reached, I hereby grant Clearview Community Church to act on my behalf in seeking medical attention by contacting 911.

Please type your full name in agreement:

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