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Factory Youth Center Registration

Home > Factory Youth Center Registration

Factory Youth Center Registration Packet

Effective September 1, 2023 – August 31, 2024

Student 1
Student’s Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Allergies / Health Concerns*
Medications*
School*
Grade*
T-Shirt Size*
Student 2
Student’s Name
First Last
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Allergies / Health Concerns
Medications
School
Grade
T-Shirt Size
General Information
Parent(s) / Guardian(s) Name(s)*
Address*
Street Address Address Line 2 City State ZIP Code
Family Email*
Child(ren) Live(s) With*
- Mom
- Dad
- Both
Parent Cell*
Student Cell
Emergency Contact
Name*
First Last
Phone*
Relationship to Student*
Educational
Does your child have an IEP?*
- Yes
- No
What is the IEP for?*
Medical
Is there medical or hospitalization insurance which provides benefits for your student(s)?*
- Yes
- No
Name of Insurance Company*
Group/Policy Number*
MEDICAL AUTHORIZATION / CONSENT
I hereby request and authorize the Factory Ministries Youth Center staff and volunteers, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information on file for my child and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child. To the best of my knowledge, I have listed above all of my student’s medical allergies, medications being taken, medical problems and other pertinent information.

ACTIVITY RELEASE OF LIABILITY STATEMENT
I give permission for my child to participate in all Youth Center supervised activities. I hereby release The Factory Ministries from the responsibility of any liability involving injury or accident to my child participating in Youth Center related activities. I, as the parent or guardian of the participant(s) listed above, will accept full responsibility for my child’s actions. I also acknowledge the contagious nature of disease-causing organisms, such as COVID-19, and voluntarily assume the risk that my child may be exposed to or infected by attending Youth Center activities at the Together Community Center (TCC) and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I agree to release, covenant not to sue, discharge, and hold-harmless The Factory Ministries' staff, agents, and representatives from claims, liabilities, actions, damages, costs, or expenses resulting from exposure to disease-causing organisms, such as COVID-19, and contaminated objects, as well as personal contact associated with viewing and/or inspecting property owned or occupied by others, or allowing others to enter the TCC. The Factory Ministries will ensure the thorough sanitation and cleaning of the TCC. In addition, The Factory Ministries and I agree to share information regarding any possible exposure to infected persons immediately.
Transportation Preferences
- Check if your child has permission to walk home from Factory
- Check if your child has permission to ride home with someone other than his/her parent/guardian
Name(s) of Approved Transporter(s)*
MEDIA RELEASE
The Factory Ministries maintains web sites and Facebook pages and we may post pictures and/or videos of Factory activities. Pictures and/or videos may also be displayed on bulletin boards, PowerPoint presentations, Factory flyers/brochures, and in outside publications such as local newspapers. Because your student’s image may be included in these pictures and/or videos, we must obtain your permission to post these pictures and/or videos. Although student’s names may be used in publications, no other personal information will be posted.
Please select one of the two statements below:*
- Yes, I give my permission for my student(s) image to be included in photos and/or videos as outlined above.
- No, I do not give permission for my student(s) image to be included in photos and/or videos as outlined above.
FACTORY YOUTH CENTER RULES
In order for the Youth Center to be a safe, fun place for teens to connect with each other, with adults that care, and the God that loves them-we need everyone, parents and students alike to be aware of our rules. Please go over our rules with your son/daughter and sign that you both understand and agree to abide by our guidelines. Failure to follow these rules will result in disciplinary procedures that might include suspension or expulsion of the student.
My signature below affirms that my child(ren) and I agree to follow all policies and guidelines as described above.
Name of Parent / Legal Guardian*
First Last
Date*
MM slash DD slash YYYY
If your child(ren) attend(s) Pequea Valley, please consent again below.
Consent for the Release of Confidential Information
As we continue to partner together to support your family, we are asking for your written consent for The Factory Ministries and Pequea Valley School District to share applicable and appropriate information regarding your son/daughter.

My child(ren), listed above, and I agree that The Factory Ministries and Pequea Valley School District can share information.

I understand that my information will be shared between The Factory Ministries and Pequea Valley School District staff members who work directly with my son/daughter.

The Factory Ministries and the Pequea Valley School District may release my information for service coordination and programming support. Information will be shared on a “need to know” basis only, as applicable to each resource. This release authorizes The Factory Ministries and Pequea Valley School District to disclose information regarding any discipline, grades, attendance, mental illness, developmental disabilities, alcohol and/or drug treatment, physical illness(s) and test results.

This release is valid until one year from today’s date , at which time it will be renewed as needed. I understand that I can revoke this release in writing at any time; however, I understand that written revocation of this release will not affect disclosures of information that have already been made in reliance on this release, before the time I revoke it.
Name of Parent / Legal Guardian
First Last
Date
MM slash DD slash YYYY

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