Wednesday Night Live Registration

Contact

Student Name

Student Birthdate

School

Grade

Parent/Guardian Name

Home Address

Phone

This address will receive a confirmation email

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Other Emergency Contacts or additional Information

Please List Anyone besides the Parent/Guardian to whom your child can be released

Medical

By signing this section you give permission for First Presbyterian Church to obtain emergency medical treatment for your child, in the very unlikely event that your child needs assistance and a parent cannot be reached.

List Allergies, Medical Conditions and/or Medications

Physician

Any other special health, behavioral or physical needs/limitations/special abilities

Parent/Guardian Signature

Media Release

By signing this, I give permission for photgraphs and videos of my children to be taken and used in print and online media. Children will never be identified in photos online!

Parent/Guardian Signature

Today's Date

Permission

By completing this form, I give my child permission to participate in all regular activities associated with Wednesday Night Live (including scheduled field trips) during the 2025-26 school year.

Parent/Guardian Signature

Today's Date

Description

This form will register your child for Wednesday Night Live. If you have questions, contact the church and we will gladly give assistance!

Wednesday Night Live Registration

Description

Please Fix the Following