Program Application

Fields marked with * are required


Student Information
  I give permission to ECM Youth Ministry to send text (or email if no cell phone) alerts to the student in order to convey pertinent program information.
 
Parent/Legal Guardian Contact Information
  I give permission to ECM Youth Ministry to send text (or email if no cell phone) alerts in order to convey pertinent program information.
  I give permission to ECM Youth Ministry to send text (or email if no cell phone) alerts in order to convey pertinent program information.
Non-Parent/Guardian Alternate Pick Up & Contact Information
Student Medical and Other Information
Program Participant Release Permissions

Our staff will ONLY release your child to those previously listed on this form unless otherwise communicated to the program director or assistant director.

(Photo ID may be requested before releasing student)
My child has permission to be released to families of other program participants who are specifically listed below. (Please list by last name only.)
My child has permission to be released without adult supervision in order to walk home, ride bike, take bus, drive (if licensed driver), etc.
Photo Release
I give permission for my child to be photographed or filmed during this program for publication in print OR electronic form on Erie City Mission's and other partnering agencies' brochures, newsletters, websites, social media accounts, etc.
Medications staff have permission to administer to my child: (Please indicate Yes or No for each medicine)
Tylenol (Acetaminophen): (Pain, headache) Advil (Ibuprofen): (Pain, inflammation, cramps)
Tums (Antacid): (Stomach pain) Ivarest (Anti-Itch Cream): (Bug bites, poison ivy)
Benadryl (Diphenhydramine): (Allergic reactions)