Youth Group Registration Form

Student Information

First Name *

Last Name *

Date of Birth *

Gender *

School Grade *

School *

Contact Information

Email Address *

Mobile Number *

Communication

I want to receive monthly updates from Port Youth via *

Text Message

Email Address

My Student (I'm Feeling Lucky)

Emergency Information

Allergies/Dietary/Special Needs?

Emergency Contact Information *

Tip: Name. Mobile. Relationship

Guardian Commitment

I hereby grant permission for my student to attend Port Youth including any activities or trips organised and run by the church, its staff and its volunteers. I also understand that I am still responsible for the actions of my student. I agree that in the event of a medical emergency where I cannot be contacted that leaders will arrange the best possible medical care. I agree to pay in full for all medical costs involved. I will not hold liable Port Anglican or its agents for any loss or injury incurred.

I also grant permission for my student to be transported by a youth leader aged over 18 if I have been informed, or in the case of an emergency.

I hereby grant permission for Port Anglican, its representatives and any of its organisations the right to take photographs or video of my student while they are attending an event or activity associated with Port Anglican. I also authorise Port Anglican the right to copyright, use and publish all media in print and/or electronically.

By Writing My Name Below I Agree To The Terms Set Above *

Student Commitment

I will respect people and help everyone have a good, safe, and fun time.If I am disrespectful or make people feel unsafe then I may not be allowed to participate in activities, my parents may be phoned or asked to pick me up. I understand that Port Youth is completely drug and alcohol free.

By Writing My Name Below I Agree To The Terms Set Above *