2023-2024 Jr. HIGH YOUTH

Child's Name

Birth date

Parent/Guardian

Address

This address will receive a confirmation email

Phone

Grade

Medical/Health Insurance Information

Medical Doctor & Phone Number

Insurance Company

Policy Number/Group Number

Any Allergies/Medications/Medical Issues

Emergency Contact Name & Phone Number

How will your child be leaving once the Walk program ends each Monday?

Permission for Publicity

On occasion, Gulf Breeze Presbyterian Church takes photographs or makes an audio or videotape recording of children and/or adults involved in church/youth activities. I consent to the use of any such audio or visual records of the child names above or me, if I am participating to be used, distributed or displayed as agents of the church see fit.

Permission for Publicity

I give permission I DO NOT give permission

Permission/Waiver Release of Liability

By signing this waiver form, I grant permission for the child named above or I, if I am a participant, to participate in and engage in the Jr. High School Youth Program of Gulf Breeze Presbyterian Church. My child or I are physically and mentally able to participate in these activities unless I have already discussed it with one of the leaders. I acknowledge that there are certain risks involved in said activities and have discussed them with my child if necessary. I release Gulf Breeze Presbyterian Church, its affiliates, volunteers, and employees of all responsibilities for any injuries, to body or property, which may occur to my child during these activities, except for negligence. In the event of an emergency, in which I or the alternate contact cannot be reached, I authorize the adult leaders to make medical decisions for my child, and to administer first aid, if deemed necessary. I further agree to indemnify and hold harmless Gulf Breeze Presbyterian Church and its affiliates, volunteers, and employees of any and all claims arising from my child’s or my participation in activities or as a result of injury or illness of my child or me during such activities, including but not limited to exercising any medical decisions or administering any first aid in the circumstances referred to above, except for negligence. I represent that I am the participant, or parent/guardian of child listed above, who is under 18 years of age. I have read the Permission/Waiver Form and am fully in agreement with the contents thereof. I give permission for the child named above or I to fully participate in the activities of Gulf Breeze Presbyterian Church. If you agree, state I agree with your name.

Signature of Participant or Parent/Guardian

Date:

Description

August 28, 2023 to May 22, 2024 from 2:00 pm - 4:00 pm

Students who attend the Middle School programs at GBPC. We follow the SRC School Calendar.

2023-2024 Jr. HIGH YOUTH

Description

Please Fix the Following