rezYouth Registration

Student Info

Student's Name

Grade

Age

Home Address

Medical Info

Emergency Contact Person

Emergency Contact Phone

Health/Allergy Issues, if any

Optional

Physician/Clinic Name

Physician/Clinic Phone

Parent/Guardian Info

Parent/Guardian Name

Home Phone

Cell Phone

Optional

May we send you text messages? Yes No

This address will receive a confirmation email

Church currently attending?

Safety

We expect students attending rezYOUTH to remain at Resurrection UMC for the duration of the program,6:30–8:00 pm. If a student leaves the building without permission during programming, the parent/guardian or the emergency contact will be called. If you need to pick up your student early, please come into the building and contact a staff person.

Consent

I, the parent/guardian listed above, give permission for my child (student's name listed on form above) to attend rezYOUTH at Resurrection United Methodist Church of Hastings.

Please type your initial below. Your initials represent your authorized signature for consent purposes on this form.

Today's Date

Description

Wednesdays, 6:30-8:00 pm

For any one in grades 6-12. Please fill out this form and click submit.

rezYouth Registration

Description

Please Fix the Following