HYC 2017 Registration and Medical and Information Form
Please fill out this form and click submit.
Date of Birth
This address will receive a confirmation email
Emergency Contact Name:
Other Family Member
Emergency Contact #
Health History and Information
Below please mark any of the conditions your child may have experienced. If there are none, please select the "To my knowledge, my child has no health conditions"
Frequent Stomach Upsets
To my knowledge my child has no medical conditions
If your child does not have any conditions listed, but does have a medical condition the staff needs to be made aware of, please list it here.
If your child takes any medication that is prescribed or over-the-counter medication, please list the type of medication and treatment details here. PLEASE NOTE ALL MEDICATION, INCLUDING OVER THE COUNTER MEDICATION (INCLUDING BUT NOT LIMITED TO TYLENOL), MUST BE LISTED IF YOU APPROVE THE STAFF DISTRIBUTING THE MEDICATION TO YOUR CHILD. ALSO ALL MEDICATION MUST BE IN IT'S ORIGINAL BOTTLE NOT MIXED WITH OTHER MEDICATIONS.
Date of Last Tetanus Shot
List any activity restrictions, if there are none, please type N/A
The insurance of First Pentecostal Church is only a secondary insurance. If you have medical insurance your carrier will be billed for medical charges in the case of illness or injury while your child is on a child related activity. Please list your insurance information below, if you do not have insurance, please type the statement, "There is no personal insurance on this child" in the box below.
Policy # ( If no insurance, please type NONE)
Guidelines and Student Acknowledgement
Please read with your student and have your student initial each line below.
¥ It is never appropriate for girls to be in the boys' rooms or the boys in the girls' room.
¥ You should be dressed appropriately when you are in the hallways and outside your room.
¥ Ladies should wear dresses or skirts that cover the knee, and men should wear pants. Sleeves should cover the upper arm. Avoid low necklines; tight, extremely thin, or sheer clothing.
Ladies should not wear eye makeup, blush, mascara, lipstick, or colored nail polish
¥ One wedding set, class ring, or promise ring may be worn. Rings on both hands are unacceptable and no other jewelry may be worn.
¥ When waiting for your friends of the opposite sex, you should wait in the lobby and not at their door or on their floor.
¥ Each attendant will be assigned to a chaperone. Your chaperone must know where you are at all times. No one leaves the hotel without a chaperone. This is Mandatory .
¥ Electronics may be used with earphones only and all listening material must be Christian.
¥ Everyone must attend all services. No running in and out of church . No cell phone use during church times.
¥ Participants 17 and younger will need to stay with their group at all times. Those 18 - 20 years old will need their parents to write a letter in order to leave the youth group at any time during the trip. Youth 21 + will be given more liberties, but they will need to communicate their plans to their assigned chaperones.
¥ Participants agree to abide by the standards of First Pentecostal Church and to be accountable to the chaperones appointed by the pastor. This includes matters of dress, curfew and behavior.
¥ Parents will be contacted to pick-up a child that does not abide by the guidelines that have been set forth. Any damage to hotel rooms or the bus will be billed to the parents of the party responsible.
I have read the guidelines above with my parent(s) and will abide by them.
Please read, and then type Your name and date below.
I, the parent of the child listed on this form, hereby give permission to my child to attend the function listed at the top of this form. I realize that my insurance is primary insurance and that the insurance of First Pentecostal Church is only the secondary insurance. Furthermore I understand that any medication, including everyday over the counter medication cannot be distributed unless I give my consent and list the medication and dosing instructions listed above. Finally, I have read and understand the guidelines listed above. By typing my name below, I hereby agree to these terms and conditions and give my permission.
Signature of Parent
Date form completed
Please upload the notarized copy of the Out of County/State form
Down Payment (85.00)
Pay in Full (170.00)
Credit/Debit Card Number
Name on Card
Card Billing Address
Please fill out this form and click submit.
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