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Registracion del Participante

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Westminster Presbyterian Church

Location

2040 Washington Rd

Pittsburgh, PA 15241

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Contact Faith Kemmler:

412-407-3774

kemmler@westminster-church.org

Primero, cuéntenos sobre usted:

Información de los Padres

Registration forms must be filled out by a parent/guardian of the child. Forms filled out by other people will not be considered valid.

Nombre

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Apellido

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Correo Electrónico

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Dirección 1

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Dirección 2

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Ciudad

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Estado/Provincia

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ZIP/Código Postal

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Teléfono de Contacto 1

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Teléfono de Contacto 2

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Emergency contact name (must be different than parent 1)

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Relación del Contacto de Emergencia

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Teléfono del Contacto de Emergencia

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Parent 2 Name

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Parent 2 Phone Number

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Parent 2 Address (if different from above)

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Is Westminster your home church? If not, where do you typically attend?

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Cuéntanos sobre tu participante

Children entering kindergarten through 6th grade in the fall of 2026 are eligible to participate in the program.

Nombre

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Apellido

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Age (as of June 22, 2025)

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Grado Entrando

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Género

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Fecha de nacimiento

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Talla de Camisa

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Alergias

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Preocupaciones Médicas

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Do you have a friend you would like to be placed with? If so, who? (must be same grade, requests are not guaranteed)

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Anything else we need to know about this child?

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PHOTO/VIDEO RELEASE

I understand that by participating in Westminster Presbyterian Church worship and activities, I/my child(ren) may be photographed and/or videotaped. I hereby assign and authorize the producer, Westminster Presbyterian Church, the rights (all rights) in and to such videotape and photography. I also authorize said producer, without limitation, the right to reproduce, copy, exhibit/publish, and distribute any such videotape and/or photographs, and expressly waive any rights or claims I may have against Westminster and/or any of its Affiliates, Subsidiaries, or Assignees except as outlined in this contract.

CONSENT, RELEASE, and INDEMNITY

I understand that participation in any events at Westminster Presbyterian Church can present a risk of harm to the participant and that I have a personal responsibility for assuming any and all medical, hospital, and related expenses that may result from my own or my child(ren)’s participation in any of events at Westminster Presbyterian Church. I hereby release Westminster Presbyterian Church, affiliated and sponsored organizations, and its personnel, and agree to indemnify and hold harmless the church and its personnel from and against any liability of any nature whatsoever for any injury to myself and/or my child(ren) resulting or arising in any way from my/their participation in any events offered through Westminster Presbyterian Church. I understand WPC provides no medical coverage. Submitting this form acts as your signature for the above statement and states that all above information was completed accurately by the parent or legal guardian of the child(ren) aforementioned on this form.

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