Youth Registration Form
Youth Registration Form

* First Name:
* Last Name:
* Address:
* City:
* State / Province
* Zip Code:
* Phone:
* Email:
Please list known allergies, if any.
* Birthdate
* Age/Grade
Current medications, if any
Other information
Mother's Name
Father's name
Mom's Cell Phone
Dad's Cell Phone
* I would like to register my youth for (check all that apply)
Sunday BLAST
Music Program
Wednesday Outlet
Youth Group Program/Trip
* Please list an emergency contact if a perent is unavailable (name & phone number)
* I give my consent for any pictures taken of my youth to be shared in any future publications and/or on the church's website (no names will be used)
I give full permission for my youth to attend programming at Chelsea First United Methodist Church. I also give permission to the leaders of this program to secure emergancy medical or surgical treatment for my child if there is insufficient time to contact me.
* Parent/Guardian Name
* Date

* Indicates required entry field