Youth Ministry Registration Form

Youth Personal Information


Parent(s)/Guardian(s) and Emergency Contact Information


Emergency Contact 


Parent Support

Without the help of our Parents, our youth ministry wouldn't be as successful. Please select any of the Support Roles down below that you would be interested in serving. 

Permission and Medical Release, Wavier of Liability, and Photo and Media Release

Permission and Medical Release. I am the parent, guardian, or family representative (Representative), of the above mentioned youth participant (Registrant), a minor,  being registered for activities and events sponsored by First United Methodist Church of Benton. I give permission for the Registrant to participate in the Youth Ministries and other Ministries being organized at FUMC Benton. I do further give my consent for the Director of Youth Ministries, properly appointed staff of First United Methodist Church of Benton, governance members, volunteers, and affiliates arising out of or relating to the activities and events held to secure the administration of medical treatment or medication for the above named Registrant during the course of their involvement. I agree to hold such persons free and harmless of any claims, demands or suits for damages arising from the giving of such consent I agree to pay either directly or through my or our own insurance, all medical and hospital costs and to be solely responsible for any treatment and the cost thereof. I will keep my contact information up to date so I can be reached as needed. I further affirm that the health insurance information provided below is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home on my own expense should they become ill or if deemed necessary.

Insurance Information

Waiver of Liability. In consideration of each Registrant being allowed to participate in this activity, and intending to be legally bound, I, as Representative, hereby waive, release, and agree to indemnify FUMC Benton from and against any and all rights and claims for damage, injury, accident or liability which I or any other Registrant, our respective successors and assigns, may now or in the future have against FUMC Benton, its staff, governance members, volunteers, and affiliates arising out of or relating to the activities and events held. As Representative, I acknowledge that the Registrant is participating at their own risk. I agree to assume full financial responsibility for any damage or injury caused by any Registrant. FUMC Benton staff members retain rights granted to them by law.
Photo and Media Release. FUMC Benton occasionally takes photos or videos of its activities, programs, and events. By registering for youth activities and events at FUMC Benton and as a Representative of each Registrant, I consent to the use of each Registrant’s likeness in photographs, videos, or voice recording by FUMC Benton for promotional and educational purposes, whether non profit or commercial. I waive any right to inspect or approve the use of any Registrant’s likeness and any compensation for such usage. To opt out of this photo consent, I understand I can contact the individual listed in the confirmation email. When photos or videos are used, participants will not be identified by name, participants' personal social media accounts will not be tagged, and locations will not be tagged as well.
With my signature below, I have read through each statement above and hereby agree to the policies and Agreements of the Youth Ministries of First United Methodist Church of Benton.