To e-mail: highlight the page, copy, click on the following address, buckinghamkids@bcc.necoxmail.com then paste into the new e-mail and fill in your information.Or return the form to Mrs. Fisher at church or in her church mailbox

Please complete BOTH PAGES

Name:_________________________________________________________  Grade:_____________________________

 Home Phone:___________________________________  Birthday:___________________________________________

 Address:___________________________________________________________________________________________

 School:______________________________________________  Youth Cell #/ITouch #__________________________

May we text/e-mail you ______________ yes ______________no ______________Email only _____________Text only

Youth Email:_______________________________________________________________________________________

Family Email:______________________________________________________________________________________

Family Contact:____________________________________________ Work Phone:______________________________

Relationship to Youth_______________________________________ Cell Phone:_____________________________

Family Contact:______________________________________________ Work Phone:____________________________

Relationship to Youth:__________________________________        Cell Phone:____________________________________

Other Emergency Contact:_______________________________       Phone:_________________________________

*Do you have any allergies (food, bees, medications, etc.) or other concerns ((injuries, etc.) that might limit your participation in activities? ____________________________________________________________________________

* I do___ do not___give permission for my child’s photo to be taken during activities, with the understanding that pictures might be used (with or without names attached) in Buckingham Church publications.

_________________________________________________________________________________________

Buckingham Congregational Church, Glastonbury

Indemnification, Release, and Medical Treatment Consent Form

I, ______________________________________________, am the parent or guardian having legal custody of

____________________________________________, a minor, age_____, born on__________________,______, who is, with my permission, enrolled in Buckingham Congregational Church, Glastonbury’s Youth Program. I hereby authorize the Youth Director of Buckingham Church or any other adult acting as an agent or representative of Buckingham Church to take any and all actions that may be necessary or proper to provide for, or arrange for the provision of, the healthcare of such minor, including, but not limited to, (i) providing for such health care at any hospital or other institution , or employing any physician, dentist , nurse, or other person for such health care, and (ii) consenting to and authorizing any health care, including but not limited to the administration of anesthesia, the taking of X-rays, the performance of tests and operations, and other procedures, by physicians, dentists, nurses, and other medical personnel. I agree to be responsible for any and all charges incurred in connection with any care or treatment rendered pursuant to this authorization, even if an employee, agent or representative of Buckingham Church has signed documentation promising to pay for such care or treatment. On behalf of the minor listed above, the minor’s parents and/or legal guardians, I agree to defend, hold harmless, indemnify and release Buckingham Church and its officers, trustees, employees, agents, representatives, volunteers, and all others who are involved in the Youth Program from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from such minor’s participation in the Youth Program. This release includes claims based on the negligence of Buckingham Church and its officers, trustees, employees, agents, representatives, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence.

Parent/Legal Guardian Signature_________________________________________________ Date:__________________

Physician’s Name:___________________________________________________ Phone # ________________________

Insurance Carrier___________________________________________ Group #/id:_______________________________

Name of Insured:____________________________________________________________________________________

Preferred Hospital:*_________________________________________________________________________________

*The signer acknowledges that Buckingham Church does not guarantee that the preferred hospital will be utilized.

 Youth Interests Survey 2012-2013`

Student Name: ______________________________________________________ Grade:________________

Do you sing or play and instrument?___________________________________

Do you play on a sports team?________________________________________

What are some of your hobbies? ______________________________________

 Any cool/weird/interesting talents or skills? ____________________________

 What are 3 things you would like to do in our Youth Program this year? _________________________________________________________________________________________

_________________________________________________________________________________________

 Would you invite a friend? _______________ Will you volunteer for our Puppet Ministry? ________________

 What else would you like us to know?_________________________________