Elysburg Presbyterian Church

Ignite Elementary Youth Group Signup Form

Ignite is for students in Kindergarten through 4th grade. Parents are encouraged but not required to stay and participate. It is the parent/guardians responsibility to communicate any special requirements or concerns regarding allergies, health issues or medication to church volunteers at the time of drop off.

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Emergency Contacts

Authorized Pickup Persons other than the above named parent/guardian

In case of a medical or other emergency while my child is under the church’s supervision, I understand that church staff or volunteers will attempt to contact me immediately; however, in the event that I cannot be reached, or when a delay may further jeopardize my child’s health, I hereby authorize church representatives to act on my behalf and to take the emergency measures including administering first aid/CPR and agree to hold Elysburg Presbyterian Church free and harmless of and from all claims and suits brought by or on behalf of said child for or on account of emergency care.

Signature

< Back

Next >

Submit

Join Ignite

Ignite Elementary Youth Group Signup Form