Child and Youth Release Form Fall 2026/27

Child/Youth Information

Name

Nickname

Pronouns

Grade

Birthdate

School

Primary Address

Secondary Address

Guardian Information

Guardian Name 1

Cell Phone Guardian 1

Email Guardian 1

This address will receive a confirmation email

Guardian Name 2

Cell Phone Guardian 2

Email Guardian 2

This address will receive a confirmation email

Emergency Contact

Emergency Contact Name 1

Emergency Phone 1

Relationship to Child 1

Emergency Contact Name 2

Emergency Phone 2

Relationship to Child 2

Other Important Information about My Child

My child can be picked up by the following persons:

My child has permission to walk home alone.

Yes No

List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction.

Allergies

Additional comments or concerns

Anything about my child's safety, or physical, behavioral, or emotional information that would help the adult leaders.

Medical Authorization

In the event of illness or injury, I authorize church personnel and volunteers to secure emergency medical treatment for my child if I cannot be contacted in a timely manner. I authorize physicians, hospitals, emergency medical personnel, and other licensed healthcare providers to provide treatment they determine is reasonably necessary. I understand that I am financially responsible for medical expenses not covered by insurance.

By typing my name on the line below, representing my signature, I agree to the above Medical Authorization.

Parent/Guardian Signature

Parental Consent

I give permission for my child (the Participant) to take part in St. Paul's UCC children's and youth ministry activities, events, trips, and childcare, from the date I submit this form until December 31, 2027.
LIABILITY RELEASE: I understand that these activities, including recreation and travel, carry ordinary risks, and on behalf of my child and myself I accept those ordinary risks. I release and agree not to hold St. Paul's UCC, its pastors, directors, employees, volunteers, and teachers responsible for accidental injury, illness, or property loss arising from those ordinary risks. St. Paul's, its pastors, directors, employees, volunteers, and teachers shall only be liable for willful misconduct and not for ordinary negligence. I understand St. Paul's carries insurance for its ministries.
EARLY RETURN HOME POLICY: If my child needs to return home early for medical, disciplinary, or other reasons, I am responsible for arranging and covering transportation.
TRANSPORTATION PERMISSION: I give permission for my child to ride in any vehicle driven by an approved, licensed adult chaperone during St. Paul's activities. My child and I understand that seat belts must be worn at all times.

By typing my name on the line below, representing my signature, I agree to the above Parental Consent.

Parent/Guardian Signature

Photo Release for Children and Youth

I agree that St. Paul's UCC may photograph and record my child's likeness and activities (Images) during church-related activities. I grant St. Paul's UCC permission to use, re-use, publish, re-publish, and edit the Images for church communications, including the church website, social media, newsletter, printed materials, and other church purposes, in any medium now existing or later developed, worldwide and with no expiration. I waive any right to inspect or approve the finished use, and I release St. Paul's UCC from any claims arising out of this use, including claims for invasion of privacy. I am my child's parent or legal guardian, I am over 18, and I have the legal capacity to sign by typing my name below.

Yes No

By typing my name on the line below, representing my signature, I agree to the above Photo Release.

Parent/Guardian Signature

Description

Please fill out this form and click submit.

Child and Youth Release Form Fall 2026/27

Description

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