Grade of Student *
Select… 8th 9th 10th 11th 12th Out of High School Other
Gender of Student
Select… Male Female
Student Cell Number
If applicable
Student Email
If applicable
Allergies/Dietary Restrictions *
Please list any allergies or medications taken that we should be aware of.
Special Needs *
Please list and explain any special needs or exceptionalities that your student may have.
Primary Parent Relationship to Student *
Emergency Contact Name *
In the event of an emergency where we cannot reach you, please tell us about another person we can contact.
PERMISSION *
I, named below, agree to allow the student listed on this form to participate in Impact Youth Ministry programs with New Life Assembly Church. I affirm that I have the legal right to register the student and to sign associated waiver forms for this program. I also agree to allow the student to participate in occasional offsite activities at Valley Pond, located at 4765 LaSalle LN, Petrolia, which will be communicated in advance as part of the programs with New Life Assembly Church.
MEDICAL RELEASE - PLEASE READ *
In the unlikely event that my child becomes sick or injured during Impact Youth, I do hereby authorize the directors of New Life Assembly Impact Youth to apply first aid to my child and if applicable, transport my child for medical attention either by private vehicle or ambulance, in which case I will accept full responsibility for their cost. I understand that all attempts will be made to contact me in such an event. I also understand that all events will be structured from a safety perspective.
MEDIA RELEASE *
Pictures and videos will be taken from time to time during programs. Do you give permission for us to publish these photos/videos in promotional materials (newsletters, flyers, posters) and our online media platforms (Website, YouTube, TikTok, Facebook, Instagram)?
WAIVER - PLEASE READ *
As my student participates in the Impact Youth program, I understand that under no circumstances will the Church Pastors, Impact Youth Leaders, NLA staff, or Board of New Life Assembly Church be liable to me or to any other person for injuries, damages, loss of property, or costs incurred by, or resulting, from any unauthorized actions on the part of any child taking part in the Impact Youth program. I release and indemnify New Life Assembly Church from any and all claims.
DIGITAL SIGNATURE *
Please type your FULL NAME as your digital signature.
Submit
