*indicates a required field

Parent / Guardian Information


Parents / Guardian*

Relationship to Child*

Spouse Name (If married)

Address 1*

Address 2

City*

State*

Zip Code*

Primary Phone*

Additional Phone

Additional Phone Type

Email Address

Emergency Contact (Name & Phone)

Relationship to Child

Select Children's Program*
AWANA (Wednesday Nights)Discovery Land (Sunday Mornings)Both AWANA & Discovery LandAWANA Special EventNone - Please Contact Me for More Info

Photo Authorization
I authorize Upper St. Clair Alliance Church to use and publish photographs of my child or children, on in which my child or children may be included, in any church publication. This includes church videos, website, and other promotional materials. I hereby release the church and its employees and agents from all claims and liability relating to said photographs. I understand that if I should change my mind about this decision, I may contact the church office at any time.

YesNo

Communication
A policy is in effect that communication is to be used solely for the dissemination of information. I grant permission for Ministry Personnel (staff and volunteers) to communicate with you via telephone, email, social media and text:

YesNo

I/we, the parents or guardians named above, authorize one of the Upper St Clair Alliance Church ministry staff to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above. I/we, named above, undertake and agree to indemnify and hold blameless Upper St Clair Alliance Church, its pastors, representatives, and board of elders from and against any loss, damage, or injury suffered by the participant as a result of being part of the activities of the Upper St Clair Alliance Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to regular events of Upper St Clair Alliance Church.

I have read, understood, and agree with the above and sign it to cover all Student Ministry activities for the program year effective as stated below.

(By typing your name above, you are providing e-signature permission)

Information received is confidential and is being gathered for the purpose of serving your child while in the care of Upper St Clair Alliance Church. Any information collected here serves to authorize Upper St Clair Alliance Church’s staff and volunteers, to obtain medical assistance in emergencies, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates requirement of our insurance company and legal counsel. If you wish Upper St Clair Alliance Church to limit the information collected, or to view your child’s information, please contact us.


Child's Information:


Child's Name*

Current Grade*

Gender*

Birthday*

Food Allergies?*

List of Food Allergies:

Medical, Physical, Emotional or Behavioral Concerns we should be aware of?*

Explain Your Concerns:

Is your child bringing any medication with them?*
YesNo

If so, please list:

(Or continue below to add more children)


Additional Children:


Child's Name

Current Grade

Gender

Birthday

Food Allergies?

List of Food Allergies:

Medical, Physical, Emotional or Behavioral Concerns we should be aware of?

Explain Medical Concerns:

Is your child bringing any medication with them?*
YesNo

If so, please list:

Click here to go to Submit button
(Or continue below to add more children)


Child's Name

Current Grade

Gender

Birthday

Food Allergies?

List of Food Allergies:

Medical, Physical, Emotional or Behavioral Concerns we should be aware of?

Explain Medical Concerns:

Is your child bringing any medication with them?*
YesNo

If so, please list:

Click here to go to Submit button
(Or continue below to add more children)


Child's Name

Current Grade

Gender

Birthday

Food Allergies?

List of Food Allergies:

Medical, Physical, Emotional or Behavioral Concerns we should be aware of?

Explain Medical Concerns:

Is your child bringing any medication with them?*
YesNo

If so, please list:

Click here to go to Submit button