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KIDS & YOUTH REGISTRATION FORM
Parent Information
Parent First Name
*
Parent Last Name
*
Email Address
*
Phone Number
*
Relationship to Child(ren)
*
Mother
Father
Grandparent
Aunt/Uncle
Sibling (over 18)
Other (write in below)
Other (write in below)
Additional Parent/Guardian: First Name
Additional Parent/Guardian: Last Name
Additional Parent/Guardian: Phone Number
Additional Parent/Guardian: Relationship to Child(ren)
Mother
Father
Grandparent
Aunt/Uncle
Sibling (over 18)
Other (write in below)
Other (write in below)
Street Address
*
City
*
State
*
Ohio
Pennsylvania
Other (write in below)
Other (write in below)
Zip Code
*
I, the parent or official guardian of the child(ren) listed below, grant permission to Victory Church and its representatives, the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of my child for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium, including internet-based. I hereby release Victory Church and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my child’s statements that were given during an interview, with or without his/her name, for the purpose of advertising and publicity without restriction. I waive my child’s right to any compensation. All prints, videos, and digital reproductions shall be the property of Victory Church.
*
Yes
No
If you answered Yes to the question above, please sign below.
clear
Child #1
First Name
*
Last Name
*
Birthdate
*
+
Gender
*
Male
Female
Allergy or Medical Alert
Special Needs
Current Age or Grade (2024-2025 School Year)?
*
0-12 months
1 year old
2 years old
3 years old
4 years old
5 years old (Pre-K)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child #2
First Name (Child #2)
Last Name (Child #2)
Birthdate (Child #2)
+
Gender (Child #2)
Male
Female
Allergy or Medical Alert (Child #2)
Special Needs (Child #2)
Child #2- Current Age or Grade (2024-2025 School Year)?
0-12 months
1 year old
2 years old
3 years old
4 years old
5 years old (Pre-K)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child #3
First Name (Child #3)
Last Name (Child #3)
Birthdate (Child #3)
+
Gender (Child #3)
Male
Female
Medical Alert (Child #3)
Special Needs (Child #3)
Child #3- Current Age or Grade (2024-2025 School Year)?
0-12 months
1 year old
2 years old
3 years old
4 years old
5 years old (Pre-K)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
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