Youth club 2014-15

YOUTH CLUB 2014-15

Youth Club at Sunset Hills United Presbyterian Church begins on

Wednesday, OCTober 1,2014

3:30 3:50 4:15 4:50 5:25 5:40 6pm

K-2 snack opening class activity music/worship dinner dismissal

3-5 snack opening activity class music worship dinner dismissal

Wednesday, Oct 1: Youth Club Begins

Wednesday, Nov 26: No Youth Club: Thanksgiving

Wednesday, Dec 110: Last Youth Club Session I

SHUP Youth Club follows Mt. Lebanon School District’s snow cancellation schedule. If Lebo has a snow cancellation, there is no Youth Club. If Lebo has a snow delay, there is Youth Club
Registration and Fees
To register, please complete the Youth Club registration & payment form below and a

SHUP Contact Information/Medical Release Form

If paid before September 21, 2014

Session I fee: $35.00 per child; Full year fee: $70.00 per child

If paid after September 21, 2014

Session I fee: $45.00 per child; Full year fee $80.00 per child

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Youth Club Registration & Payment Information
Parent Name____________________________________ Daytime Phone_________________
#of children registered_____, amount enclosed______, check #______, half year/full year

(please circle one)

_____please contact me about youth club scholarships

Please make check payable to SHUP & return with a SHUP Contact Information/Medical Release Form to:
Sunset Hills United Presbyterian Church

900 Country Club Drive Pittsburgh, PA 15228

Questions? Contact the church office at 412-561-6261

SUNSET HILLS UNITED PRESBYTERIAN CHURCH

Contact Information/Medical Release: Sept 2014-August 2015

For Youth Club, Monday Mission , High School and Middle School Youth Groups

(Please complete a separate from for each child)

Child’s Name______________________________________________Birthdate______________Age______

Mailing Address (w/ zipcode)__________________________________________________________________

School __________________________________Grade_____ Church_________________________________

Contact Information
Mother’s Name___________________________________________e-mail_____________________________
Mother’s phone #’s (home)___________________(cell)___________________ (work)___________________
Father’s Name___________________________________________e-mail_____________________________
Father’s phone #’s (home)____________________(cell)____________________ (work)__________________
Other Emergency Contact___________________________________ phone____________________________
Other Emergency Contact___________________________________ phone____________________________
Medical and Insurance Information

Allergies____________________________________ Medications ___________________________

Other physical conditions/special needs____________________________________________________

Name of Primary Insured: ______________________________Company ________________________

Plan ________________________ ID and/or Group No. _____________________________________

Permission and Release to Participate
As parent/legal guardian, I give my permission for my child____________________________, to participate in

(please circle all that apply) Youth Club Monday Mission High School Youth Group Middle School Youth Group

sponsored by Sunset Hills United Presbyterian Church. Travel off site to be in church bus or private car.

I, INTENDING LEGALLY TO BE BOUND, release and discharge Sunset Hills United Presbyterian Church, its agents, employees, members, officers, and staff, of and from all claims, demands, damages, actions or suits at law or in equity, of whatsoever kind or nature, for or because of any matter or thing incident to such special event done by it or any of its agents, employees, members, officers, and staff, or omitted to be done.

The bearer of this form is hereby authorized to serve as my agent and proxy to authorize and secure any and all types of medical care including hospitalization, surgery, diagnostic testing and any other necessary or appropriate care as determined by the treating physician.
____________________________________________________ _____________________

Signature of Parent/Guardian Date