Children & Youth Consent Form

Child's First and Last Name *

1st Parent/Guardian's First and Last Name *

1st Parent/Guardian's Phone Number *

2nd Parent/Guardian's First and Last Name

2nd Parent/Guardian's Phone Number

Emergency Contact *

Emergency Phone Number *

Please include any additional information that we should know about your child (i.e: health conditions, food allergies, etc.). *

I consent to allowing photos and/or videos of my child(ren), to be utilized for Newark UPC’s social media pages, websites, and other purposes related to furthering the gospel of Jesus Christ. *

Yes, I consent.No, I do not give my consent.

Send to my physical fax address only

Children & Youth Consent Form

Children & Youth Consent Form

Jacob's Well

Contact Us