Preparing a Demo

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2026-27 Student Registration and Release

Student Name *

Student's Preferred Name / Nickname

Student's Gender

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Student's Birthdate *

Student's Grade for '26-27 *

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Student's School Attended

Student's Home Church

Student's Address *

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Student's Phone

Student's Email

Student Support and Care

Student has an IEP, 504 Plan, learning accommodation, or other support plan.

Student has sensory, communication, mobility, behavioral, emotional, or social needs leaders should understand.

Student may need help with transitions, crowds, noise, food, or small-group participation.

Please contact me privately to discuss support needs.

Please include any additional information that will help us care for your student:

Pickup and Check-Out Information

Authorized Adults *

Please list all adults who are authorized to pick up this student. Include name and phone number.

Release Options *

Release only to an authorized adult who presents the matching pickup tag or acceptable identification.

Student may be released to an older sibling listed above who is at least sixteen years old.

Student may drive themself home. (Include vehicle description / plate below).

Student may walk or bike home without an adult. Parent understands AYG supervision ends at checkout.

Other approved arrangement (please specify below).

Pickup details, special circumstances, and restrictions.

Add any court-ordered restrictions or non-authorized persons to be aware of.

Media, Communication, and Transport Consent

Photography and Video Consent *

I consent to the use of my student's image in ministry presentations, communications, printed materials, or on social media posts promoting Antwerp Youth Group.

Yes

No

Student and Parent Communication *

Parent may receive email updates, calendars, permission forms, and announcements.

Parent may receive text-message reminders or emergency updates.

Student may participate in approved group-message channels where at least two authorized adults have access.

Student may receive ministry-related direct messages only when another authorized adult or parent/guardian is included, except in an immediate safety emergency.

Local Transportation *

I consent to allow my student to be transported to local events or destinations in a church-owned, rented, or approved volunteer vehicle for routine local ministry activities when supervised under AYG policy.

Yes

No - I will provide separate permission per event.

Medical and Insurance Information

Health Insurance Company

Member / Policy ID

Group Number

Policyholder's Name

Student's Primary Physician

Physician Phone

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Allergies, Conditions, Medications, and Other Care Needs *

Select all that apply from within the dropdown menu. Please use the space below this list to provide further details and treatment instructions.

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Allergies and medical condition details / treatment instructions:

Current medications, dosage, and schedule

Medical conditions, injuries, restrictions, and accommodations

Please list any other pertinent health information that may be useful to first responders in the event of an emergency.

Emergency Medical Authorization - Choose One

CHOOSE ONE *

I GRANT CONSENT

I DO NOT GRANT CONSENT

Parent / Guardian Signature *common.clear

Parent / Guardian Name *

Emergency Phone *

Date *

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