Unhindered 2022-2023 • Elmira Pentecostal Assembly

Student Registration will be attached to this event.

Date & Time

July 6, 2022 3:15 PM - August 31, 2023 12:00 AM

100 out of 100 remaining tickets available

Type

Quantity

Student Registration

Quantity

Student Registration 0

Elmira Pentecostal Assembly (EPA) is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our church. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel. If you wish Elmira Pentecostal Assembly to limit the information collected, or to view your child’s information, please contact us.

Student's Name *

Date of Birth *

Current Age *

Current Grade *

School *

Home Address *

Mother's First Name *

Mother's Last Name *

Mother's Phone *

Father's Name *

Father's Phone *

Email For Primary Parent(s) *

Custody *

Name of Emergency Contact *

Phone Number *

Relation to Student *

Allergies/Medical Concerns *

Individuals (other than parents) who are authorized to pick up student's from EPA programs. *

Release and Permission Statement

Release and Permission Statement

I/We, the parents or guardians of the student mentioned in this form, authorize the ministry staff of Elmira Pentecostal Assembly to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/We undertake and agree to indemnify and hold blameless the ministry staff, Elmira Pentecostal Assembly, its pastors and Board of Deacons from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Elmira Pentecostal Assembly, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of Elmira Pentecostal Assembly.

I have read and agree to the Release and Permission Statement. *

Agree

Photo Release Statement

Photo Release Statement

I grant permission to Elmira Pentecostal Assembly (EPA) to use photographic images containing photograph/likeness of the student mentioned in this form, for various purposes such as printed material, publications, displays, video productions, PowerPoint presentations, etc. I also acknowledge EPA’s right to crop or treat the photographic image at its discretion.

I have read and agree to the Photo Release Statement. *

I Agree

I Disagree

Student Registration Form

Date & Time

Student Registration 0

Release and Permission Statement

Photo Release Statement