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Contact Us

  • Phone: (610)648-0707
  • Email: 
  • Mailing Address: 400 Lancaster Ave, Malvern, PA 19355

 

 

Registration for Children and Youth

Does your child have any allergies? Please provide details.

Does your student carries emergency medications?

A separate medication form will be provided for all emergency medications.

Does your student wear:

Is your student a:

Parent/Guardian 1 Address*

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Does student reside with this parent?*

Parent/Guardian 2 Address

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Does student reside with this parent?

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Phone Number 1 is:*

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Phone Number 2 is:

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Phone Number 3 is:

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Please provide name of primary care physician or practice (for example, Dr. Susan Jones or ABC Pediatrics).

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Health Insurance*

Please upload a copy of your child's health insurance card (front and back) or bring the card to the church so we can make a photocopy.

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Consent-Cell Phones and Social Media

I agree that Covenant United Presbyterian Church staff and volunteers may use cell phones and social media (e.g. texting, Facebook, Instagram, Twitter, etc.) to communicate with my child for purposes related to youth ministry and its activities at Covenant United Presbyterian Church. I recognize I may revoke this consent with a written letter at any time, and that if I have any concerns with the way social media is being used with my child, I will report it to CUPC staff.

Medical Attention Release*

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor and have given our consent for him/her to attend events being organized by the children and youth ministries of Covenant United Presbyterian Church. I/We understand that there are inherent risks involved in any ministry or related event, and I/We hereby release Covenant United Presbyterian Church, its Pastors, employees, agents, and volunteer works from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Covenant United Presbyterian Church, I/We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of the medical care not be reimbursed by the health insurance provider. Further, I/We affirm that the health insurance information provided on the following page is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.

Transportation Release

I understand the transportation to and from events might be by private car driven by CUPC staff member or volunteer cleared by our Child/Youth Protection Program. I agree that the church will not be held responsible in case of accident. I agree that the driver will not be held responsible in case of accident.

Photo/Video Release*

I understand that photos/video may be taken of my child during this activity. I agree that any pictures of my child taken at the activity may be included, without identifying information, in brochures and posts for promotional purposes. I also give consent for pictures of my child to be posted on the church website, Instagram, Facebook, etc.

Confirmation of Electronic Signature*

I have agreed to submit this application by electronic means. By checking this box and typing my name below, I am electronically signing this form.