EmailMe Form - JC Stars Youth Group at CUMC Registration

Child or Youth Name *

First Last

Child's Birthday *

MM / DD / YYYY

School *

Douglas School

Lincoln School

Clinton Elementary School

Other

Grade and School Teacher *

Parent or Guardian's Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Parent's Email *

Home Phone

### - ### - ####

Cell Phone *

### - ### - ####

Can you receive test messages on your cell phone

Yes

No

Special Medical Information (Allergies, ect...) *

Name of Emergency Contact #1 *

First Last

Phone for Emergency Contact #1 *

### - ### - ####

Emergency Contact #1 Relationship to Child

Name of Emergency Contact #2 *

First Last

Phone for Emergency Contact #2 *

### - ### - ####

Emergency Contact #2 Relationship to Child

Transportation to JC Stars *

I can provide my child's transportation.

I could provide my child's transportation and can bring other children also.

My child will need transportation (see below).

Transportation Release
I, the parent or guardian of the above named child, request the Clinton United Methodist Church to provide transportation for my child from their public school to the church on all Thursdays (starting Oct. 1, 20265 when school releases at regular time (2026-2027 school year). I understand I must send a note to the school and call the church or the JC Stars leader if there is to be a change in this arrangement. I also understand that my child will be transported by one adult driver and I release such person(s) from all liability, loss or damage to person or property that may occur during such transportation.
Partent or Guardian's Name

First Last

Type your name for the signature and date below

Medical Release
I, the parent of guardian of the above named child, give my permission to go and participate with the Clinton United Methodist Church JC Stars program during the 2026-2027 school year. I fully understand the dangers and risks involved in the activities that my child will be participating in and will assume all Responsibility of injury in connection with them, releasing and discharging the Clinton United Methodist Church and the Volunteers/Staff involved with the fictions, of responsibility. In case of emergency, I hereby give permission to the physician selected by the leaders to secure proper treatment for my child, as named above, If I cannot be immediately reached guaranteeing payment of such treatment. *

First Last

Type your mane for the signature and date below

Photo Release
I, the parent of guardian of the above named child, give Clinton United Methodist Church permission to photograph my child and use his or her pictures in the church’s digital and print communications. Clinton United Methodist Church will never publish a child’s name or any other personal information with any of its publications. *

First Last

Type your mane for the signature and date below

Today's Date Time *

MM / DD / YYYY

Email