Summerville Presbyterian Church

4845 St. Paul Blvd.

Rochester, NY 14617


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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):___________________


Street Address:______________________________________

City, State, Zip:________________________________________

Church Affiliation:______________________________________

Medical Information

Doctor’s name: Telephone #:__________________________________________

Insurance Carrier and #:_____________________________________________

Medical Conditions/allergies:____________________________________________


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:_______________________________________