Youth Registration Form 2024-2025
Please fill out this form and click submit.
Parent/Guardian Information
Name
*
Email
*
This address will receive a confirmation email
Phone
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Spouse/Partner's Name
Email
Children
Name
Date of Birth
Grade
Please select one option.
6
7
8
9
10
11
12
Name
Date of Birth
Grade
Please select one option.
6
7
8
9
10
11
12
Name
Date of Birth
Grade
Please select one option.
6
7
8
9
10
11
12
Name
Date of Birth
Grade
Please select one option.
6
7
8
9
10
11
12
Please list any accommodations needed
Health or Medical Concerns
The following is a list of medications that my child will need to take while attending St. Thomas activities. Please list the name of medication, dose and when taken.
PARENTAL CONSENT: I give full permission for my child to attend and participate in any youth activity sponsored by St. Thomas. DURABLE POWER OF ATTORNEY FOR EMERGENCY MEDICAL/SURGICAL CARE: I represent and warrant that to the best of my knowledge my child has no illness, congenital defect, or other health condition that makes my child’s participation in St. Thomas Episcopal Church, Chesapeake youth activities unsafe for my child or other participants even with reasonable accommodation of any disability. I appoint St. Thomas Episcopal Church, Chesapeake for the limited purpose of consenting to any emergency medical or surgical care for my child that may be recommended by a physician regarding any injury or illness that may arise while my child is participating in a St. Thomas youth activity. St. Thomas shall use its best efforts to contact me in advance of exercising this delegated power so that I may direct my child’s care. If I am unavailable after reasonable attempts to contact me, or if my child’s condition makes any delay medically unadvisable, then St. Thomas Episcopal Church, Chesapeake may exercise the delegated power without communicating with me first. I agree to pay all health care providers for any services rendered to my child pursuant to this delegated power, whether through health insurance or private payment. TRANSPORTATION RELEASE: I give full permission for my child/children to be transported to St. Thomas Episcopal Church youth activities, which includes permitting my child to attend and participate in activities off-site of the St. Thomas Episcopal Church campus. WAIVER OF LIABILITY: I release St. Thomas Episcopal Church, Chesapeake, its agents, employees, officers, vestry members, and volunteers, from any liability of any kind or nature that may arise in any way from my child’s participation in St. Thomas Episcopal Church, Chesapeake youth activities.
*
Media Release: I give permission for photographs or videos of my child to be taken during my child’s participation in St. Thomas Episcopal Church, Chesapeake youth activities, to be used by St. Thomas Episcopal Church, Chesapeake for promotional purposes.
*
Please select one option.
Yes, I give permission.
No, please do not take photographs of my child.
By typing your name, it acts as a physical signature.
*
Submit
Description
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