Young Peopleʼs Ministry Event Group Checkoff Form

This form should accompany all registration forms for the event which you are registering. Make more
copies of this form as needed. Please be sure to place this on the top of your registrations.
EVENT:______________________________________Todayʼs Date:_________________________
Church Name: ___________________________________________________________________
Address: _______________________________________________________________________

City, State, Zip Code: ____________________________________________________________

Pastor: ______________________________Youth Minister: ______________________________

Youth Min - Home: (_____)__________Cell: (_____)_____________Work: (_____)_____________

District (circle one)

CL (Clarksville) CO (Columbia) CK (Cookeville)
PU (Pulaski)
CU (Cumberland) MU (Murfreesboro) NA (Nashville)
Name of Registrant Adult/ Health Form Payment
Youth

Number of Participants (Including Adults) ________ X ________(Fee) = $ ____________

Before November 29 - $45  After 11.29 before 12.29 - $50  After 12.29 before 1.20 - $55
 After 1.20 - $65  Not accepted after 1.25  No Refunds after 1.15

Make Checks payable to Tennessee Conference Young Peopleʼs Ministry

Mail to: Warmth In Winter, TN Conference UMC
304 S. Perimeter Park Drive, Suite 1
Nashville, TN 37211
 Young Peopleʼs Ministry Event Registration Form
Utilize this registration form for all events sponsored by the Young Peopleʼs Ministry of the Tennessee
Conference of The United Methodist Church. A completed form only needs to be submitted one time
per year unless health or insurance information changes. ALL PARTICIPANTS BOTH YOUTH AND
ADULT must submit a completed form for the first event attended during the ministry year. This
information will be entered into a secure database at the Tennessee Conference Office and utilized as
needed for health and registration information. Your information will not be given or sold to another
party for use of any kind.

Please Print or Type Clearly Todayʼs Date _________________________

Event You Are Registering For: _____________________________________________________

District (circle one)
CL (Clarksville) CO (Columbia) CK (Cookeville)
PU (Pulaski)
CU (Cumberland) MU (Murfreesboro) NA (Nashville)

Participant Full Name: __________________________________Email: _____________________

Address: _______________________________________________________________________

City, State, Zip Code: ____________________________________________________________

PHONE - Home: (_____)____________Cell: (_____)_____________Work: (_____)_____________

Church Name: ______________________________City/State: ____________________________

Pastor: ______________________________Youth Minister: ______________________________

If non-Tennessee Conference UMC, name of other Conference, Denomination or Religious

Affiliation: __________________________________________________________

School (Currently attending): _______________________________________________________

DOB: _____________ Age: ______ Current Grade Level:______ Gender:____ Race:__________

T-Shirt Size: S M L XL XXL Other: ____________

If under age 18, Parent or Guardian of Registrant:

Name(s): _________________________________________________________

Parent Signature: __________________________________________________

Address if different from above: _______________________________________

City, State, Zip Code if different from above: _____________________________

Phone: Day (______)_________________ Evening: (______)_______________

Cell: (_______)__________________ Email:_____________________________

COMPLETE THE OTHER SIDE, PLEASE

Registration Form - Page 2
Participant Full Name: ____________________________________________________________
Please Select Yes or No
YES ---- NO: Photographs of this youth may be used for promotional purposes by the Tennessee Conference
Young Peopleʼs Ministries. At no time will their name, address, or church be identified unless specifically notified.
Special needs, i.e. physical, dietary, etc: _____________________________________________
________________________________________________________________________________

MEDICAL INFORMATION FORM

Name of Registrant: __________________________ Social Security: ______________________

Full Address: ___________________________________________________________________

Emergency Contact & Phone: _____________________________________________________

Health Insurance Provider: ____________________________ Group Policy #: ______________

Family Physician: ________________________________ Phone: ________________________

Family Dentist: __________________________________ Phone: ________________________

Allergies (food, nature, medicine): __________________________________________________

List Medications required during event

NAME OF MEDICATION DOSAGE/DELIVERY REASON TAKING

Medications will be kept in a secure location under the guidance of participants church youth ministry
leadership. If the participant is not a part of a group, the event director will administer.

Y N - I give permission for my child to be given Tylenol, laxative, or other minor medication as needed.

Describe any behavioral or emotional problems that your child has that may effect their stay at camp or event.

I understand that all reasonable safety precautions will be taken at all times by the Young Peopleʼs Ministries
of the Tennessee Conference Event Staff. I have completed the information to the best of my knowledge. In
giving my child permission to attend this event indicated, I release the United Methodist Church, Tennessee
Conference, leaders and event staff from liability for damages, losses, disease, or injuries incurred by my child.
I understand that I, or the emergency contact listed on the registration form will be contacted. I hereby give
permission to the physician or facility present to order X-rays, routine tests, and treatment for the health of my
child.
Parent/Guardian Signature: _______________________________________ Date: ___________________

Witness Signature or Notary: ______________________________________Date: ___________________