Ember Youth Registration Form

Name

Grade

School

Birthday

Phone

How did you hear about Ember Youth?

A friend A family member Instagram/Facebook/social media Google Other

If selected other, please describe here:

Emergency Contact Information

Parent/ Guardian's Full Name

Relationship to youth

Phone

This address will receive a confirmation email

Medical Safety

Does your child have any allergies or medical conditions we should know about?

Media Permission & Release Form

I, the parent or legal guardian of the child listed above, grant Ember Community Church permission to photograph and/or record my child during church-sponsored activities and events.

I understand that these images or recordings may be used for ministry-related purposes, including the church website, social media platforms, and other promotional or informational materials. I acknowledge that my child’s name will not be used without additional consent, no compensation will be provided, and all use will be respectful and consistent with the mission and values of the church.

Please check one:

YES, I give permission for my child’s image to be used as described above. NO, I do not give permission for my child’s image to be used.

Parent/ Guardian's Signature

By typing my name below, I acknowledge that this serves as my electronic signature and that I am the parent or legal guardian of the child listed above.

Date

Ember Youth Registration Form

Description

Please Fix the Following