Summerville Presbyterian Church

4845 St. Paul Blvd.

Rochester, NY 14617

585-342-4242

           office@Summervillechurch.org         map/directions link
Information and Contact Form

SPC Youth & Adult

Information/Contact Form

 

This information is required of all those who participate in Summerville Presbyterian Youth Group events. It will be kept on file in a notebook by the Director of Youth & Education. The notebook will be brought to all events.

 

Name: _______________________ Gender: ____ Circle one: Youth Adult


Tel (H):___________ (W):______________ (C):___________________


E-mail:__________________________________________


Street Address:______________________________________


City, State, Zip:________________________________________


Church Affiliation:______________________________________


Medical Information

Doctor’s name: Telephone #:__________________________________________


Insurance Carrier and #:_____________________________________________


Medical Conditions/allergies:____________________________________________


Medication(s):_______________________________________________________


When Taken:_______________________________________________________


I, the parent, authorize Deborah L. Carter, Linda Hayes or Kathy Wilkinson to obtain any needed emergency medical treatment while at an SPC Youth Group event. I also understand that SPC is not responsible for damage to or loss of youth’s personal property.



Signed: ___________________________ Date:_____________________

(parent signature)


Print name legibly:_______________________________________