Student Information

First Name:
Middle Name:
Last Name:
City, State, Zip:
Home Phone:
Student's Cell Phone:
Date of Birth:

Parent Information

Are parents members of Westminster? Parent 1       Parent 2       Both       Neither      
Parent 1
Home Phone:
Work Phone:
City, State, Zip:
Parent 2
Home Phone:
Work Phone:
Address (if different from Parent 1):
City, State, Zip:
In case of emergency, which parent should be contacted? Parent 1       Parent 2       Both parents      
Emergency contact (if neither parent can be reached)


Current School:
After-school Activities:

Special Needs

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

Stuff We Left Out

Tell us anything else we need to know

Medical Information

Please check the following areas of concern for this student:

Does your child have allergies to:

Medication (please explain):

Does your child currently, or have they ever, suffered from or been treated for any of the the following:


Does your child take medication daily?    No
If yes, please explain:

Should your child's activities be restricted for any reason? Please explain:

Please list any other important information we should know about your child:

Photo/Video Release

I understand that by participating in Sunday School and its associated activities, my son/daughter will be photographed and videotaped. I hereby assign and authorize the producer, Westminster Presbyterian Church, the rights (all rights) in and to such videotape and photography. I also authorize said producer, without limitation, the right to reproduce, copy, exhibit/publish, and distribute any such videotape and/or photographs, and expressly waive any rights or claims I may have against Westminster and/or any of its Affiliates, Subsidiaries, or Assignees except as outlined in this contract.

May we publish photographs of your child in print?
May we publish photographs of your child on our website?
May we video your child and upload videos to our website?
Students will not be identified by name in any of these publications.

Consent, Release, and Indemnity

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.

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 WROC 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.