1. First Name:
2. Last Name:
3. Preferred/Nickname:
4. Address:
5. City, State, Zip:
6. Student's Cell Phone*:
7. *OK to send program alerts to this cell phone?
    Yes  No
8. Date of Birth:
9. Email:

1. Current School:
2. Grade:

1. Please tell us about any special needs or challenges your child has

1. Tell us anything else we need to know

We would like to make you aware that by participating in Westminster Presbyterian Church worship and activities, you may be photographed and/or videotaped and therefore assign and authorize the producer, Westminster Presbyterian Church, all rights to reproduce, copy, exhibit/publish, and distribute any such videotape and photography.Children will never be identified by name in any publication, but they may appear on our website, social media pages, or in print. If you do not want your child photographed, please contact Ed Sutter.

1. Parent #1's Name:
2. Address
3. City, State, Zip:
4. Cell Phone*:
5. *OK to text program alerts to this cell phone?
    Yes  No
6. Work Phone:
7. Email:

1. Parent #2's Name:
2. Address
3. City, State, Zip:
4. Cell Phone*:
5. *OK to text program alerts to this cell phone?
    Yes  No
6. Work Phone:
7. Email:

1. Name:
2. Phone:
3. Relationship:

I understand that participation in any of the Youth/Children’s programming can present a risk of harm to the participant and that I have a personal responsibility for assuming any and all medical, hospital, and related expenses that may result from my own or my children’s participation in any of the Youth/Children’s programs, games, or activities.

I hereby release Westminster Presbyterian Church, affiliated and sponsored organizations, and its personnel, and agree to indemnify and hold harmless the church and its personnel from and against any liability of any nature whatsoever for any injury to myself and/or my son or daughter resulting or arising in any way from my/his/her participation in any programs offered through Youth/Children’s Ministries. I understand WPC provides no medical coverage.

Selecting “I Agree” acts as your signature for the above statement and states that all above information was completed accurately by the parent or legal guardian of the child aforementioned on this form.