SPC Youth & Adult

Information/Contact Form

This information is required of all those who participate in Summerville Presbyterian Youth Group events. It will be kept on file in a notebook by the Director of Youth & Education. The notebook will be brought to all events.

Name:__________________________ Gender_______ Circle one:  Youth Adult

Telephone: (H)______________ (W)________________ (C)_________________

e-mail:______________________________

Address:______________________________________________

City:_____________________ State:_________________Zip:________________\

Church Affiliation:____________________________________

Medical Information

Doctor’s name:_____________________________ Telephone:________________

Insurance Carrier and #:______________________________________________

Medical conditions/allergies:___________________________________________

Medication(s):__________________________________________

When taken:___________________________________________

I, (parent or guardian), authorize Deborah L. Carter to obtain any needed emergency medical treatment while at a SPC event.  I also understand that Summerville Presbyterian Church is not responsible for damage to or loss of youth’s personal property during events.

Signed:_________________________________  Date:__________________

Print name legibly:_________________________________