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Youth
Registration Form 

2022 - 2023



Decatur Presbyterian Church – COVID 19 DPC Youth Event Procedures

DPC Youth Minsitry Events will continue to follow Decatur Presbyterian Church’s church-wide policies for gatherings during COVID-19 unless otherwise noted. Anyone participating in a DPC sponsored event in-person is required to abide by these guidelines. Participation in DPC Youth events assumes that participants assume the risk and liability of being exposed to the virus by attending in person. These guidelines will be in effect until the Session of DPC directs otherwise. 

Decatur Presbyterian Church Actions

  • All DPC Youth gatherings will continue to abide by DPC’s Child and Youth Protection Policy.
  • Ensure all common spaces in our building are cleaned regularly
  • Hand sanitizer and disposable masks made available for all participants. 
  • If it is determined that a person at a DPC Youth event has exposed others to the virus, all participants and parents will be notified by email. 

Youth and Adult Leader Actions:

  • Youth and adults leaders will monitor their own symptoms before coming to events. 
  • Youth and adult leaders should let the DPC Youth Ministry staff know if they have tested positive for COVID-19 or  are displaying symptoms of COVID 19.
  • Individuals should refrain from attending in-person events if they have tested positive for COVID 19, are displaying symptoms, or are advised to quarantine per CDC guidelines. 
  • Each youth and adult leader is encouraged to ask for what they need to feel safe at DPC gatherings and to talk with the DPC Youth Ministry staff about any concerns they have.

My signature below acknowledges I have read the above and agree to adhere to the steps and actions listed.

Today's Date: April 26, 2024 


First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive weekly DPC Youth Ministry updates (if you are not already receiving our weekly updates)
Parent/Guardian Information

Parent's Name *

Parent's Cell phone number *

Second Parent/Guardian Name

Cell phone of second parent/guardian

Email of second parent/guardian

Address of second Parent/Guardian (if different from first)
Health and Medical Information ; Emergency Medical Release

Emergency Contact Name (not a parent/guardian, someone from a different household) *

Emergency Contact Phone Number *
Does this participant have Health Insurance Coverage?*
Yes
No
Dietary Restrictions: *
No Dietary Restrictions
Dairy Free
Gluten Free
Sugar Free/Low Sugar
Vegan
Vegetarian
Food Allergies: *
No known food allergies
Egg
Dairy
Gluten/Wheat
Peanut
Tree Nuts
Shellfish or Fish
Soy
Other
Is Allergy Life Threatening:
Yes
No
Does not apply
Does this participant carry an Epinephrine Injector (Epi-Pen)?
Yes
No
Sometimes

Allergy and dietary restrictions more information:

Does your child have any health or medical conditions that we should know about (diabetes, asthma, migraines, bleeding disorder, seizures, etc.)?

Please tell us about any known mental health concerns that we should know about.
Is this participant Fully Vaccinated against COVID-19? *
Yes
Yes & Booster
No
Not old enough yet
Has this participant received all other doctor recommend vaccines and immunizations? *
Yes
Mostly, some still in process
No

List any prescription or over the counter medications your child takes daily or as needed.

Please list any other medication that you have approved for your child to take as needed (pain medication, allergy medication, sleep aids etc)
Can we share this information with DPC Youth adult volunteers as deemed necessary in order to provide adequate support and care for your child?
I prefer that the DPC Youth Ministry staff keep this information confidential
I give DPC Youth Ministry staff permission to share this information with volunteer adult chaperones as deemed necessary.
Emergency Medical Treatment Release
I give permission for my child to participate in Session-approved events sponsored by Decatur Presbyterian Church, Decatur, GA From May 1, 2022 through August 31, 2023. In the case of emergency, I understand that every effort will be made to contact the parents, guardians, or emergency contact(s) of the registered minor. In the event that I cannot be reached, I give permission to the physician selected by Decatur Presbyterian Church to hospitalize, secure proper treatment for, and/or to order anesthesia or surgery for my child. I understand that I am financially responsible for any expense for medical care or transportation incurred on my child's behalf.*
Yes
No
Photo and Video Release
I grant permission to Decatur Presbyterian Church, Decatur, GA, to use my child's photo or video on their website, social media, or in other official organization printed publications. I also acknowledge that Decatur Presbyterian Church, Decatur, GA may choose not to use my child's photo at this time, but may do so at its own discretion at a later date. I understand that the names and personal information of my child will not be published with the photo or video.*
Yes
No
Release of All Claims
I hereby release, absolve, discharge and hold harmless Decatur Presbyterian Church, Decatur, GA and all employees and volunteers associated herewith, including but not limited to, the volunteer drivers who will be involved in the transport of the child to and from events (the "Released Parties") from all action, damages, claims or demands that the child and/or I may have against Released Parties for any personal injuries, known or unknown, or any other claims, damages or injuries that the child may have or may incur by participating in these events, including but not limited to, transportation from said events.*
Yes
No
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Child Protection
Is there any adult that is PROHIBITED from contact with this minor? *
No
Yes
Is there any adult with a restraining order regarding this minor?*
No
Yes

Details regarding prohibited adults:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Gender: *
Youth's Grade: *

Youth's School *

Youth's cell phone number (if they do not have a cell phone number, please leave blank)
May this person receive text messages with youth group info?*
Yes
No
Youth does not have their own phone

Youth's Email Address: (leave blank if you doesn't have email)

Name and Grades of Siblings: (E.g. Harry 11th, Hermione 12th, etc.)

Sports/Extracurricular Activities:
Baptized?*
Yes
No
I'm not sure
Would like more information about baptism
Confirmed?*
Yes, at DPC
Yes, at another church
No
I'm not sure
Would like more information about Confirmation at DPC
Does this participant play a musical instrument?*
Yes
No

List instruments played

Other interests (dance, art, drama, making videos, etc.)

Comments:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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