2026-27 HSCL Youth and Family Village Registration Form

Welcome, Beloved Families!

We’re so excited to welcome your child into our Youth & Family Village — a joyful space where every child is celebrated as whole, perfect, and complete. Please take a few minutes to fill out this form, one form per child, so we can get to know your family better.

Parent/ Guardian Information

Guardian Name

This address will receive a confirmation email

Phone

Are you available to volunteer?

YES! No. Maybe?

Care, Safety & Emergency Information

Youth & Family Village is committed to providing a safe, welcoming, and supportive environment for every child. Please provide the information below so we can care for your child appropriately and contact the right people in case of need. Please list at least one emergency contact other than the parent/guardian.

Emergency Contact Name and Relationship to child

Emergency Contact Phone number

Authorized Pick-Up

Full Name / Relationship / Phone

About your Child

Does your child have any allergies, medical concerns, or support needs we should know about? Please Explain

Child Name

Age

Pronouns

Please upload a recent picture of your Child.

Upload (8MB)

Additional Information

What additional programs would you family be interested in participating in?

Community Service Opportunities Nature Outings (walk, hikes, etc) Group Events (movies, live music, etc) None of the above

Does your young person have any food or other allergies for us to be aware of?

Anything you would like to share about your young person (people) that will help us better plan for their presence? Educational differences? Please share any support necessary for your child to have an optimum experience with Youth and Family Village.

HSCL YFV Permission(s)

In the event of an emergency, Youth & Family Village will make reasonable efforts to contact the parent/guardian and emergency contacts listed above.

Yes, I give permission for emergency assistance to be sought for my child if needed. No

Liability Agreement Waiver and Release Parent Consent: I hereby consent that my child may participate in the Heart and Soul Center of Light Youth and Family Village program. I state that said minor is physically able to participate in said activities. I understand that hold Heart and Soul Center of Light, its agents and its employees harmless from any and all liability claims including but not limited to, claims of injury, illness, accident, or death that occur during or by reason of participating in Heart and Soul Center of Light Youth and Family Village.

Liability Agreement Waiver and Release Parent Consent:

Yes, I agree.

Youth & Family Village and Heart & Soul Center of Light occasionally take photographs, video recordings, or audio recordings during programs, special events, celebrations, learning activities, and community gatherings. These images and recordings may be used to celebrate the life of the ministry and share the work of Youth & Family Village with families, the congregation, and the broader community.

By selecting “Yes” below, I give permission for my child’s photograph, video image, voice, artwork, or participation in Youth & Family Village activities to be used by Heart & Soul Center of Light and Youth & Family Village for ministry-related purposes, including newsletters, annual reports, printed materials, presentations, the Heart & Soul website, social media, and other ministry communications.

I understand that my child’s name will not be used with their image without additional permission, unless otherwise approved by the parent or legal guardian.

I understand that no compensation will be provided for the use of these images or recordings.

Parent/Guardian Permission

Media Waiver

Yes, I give permission for my child to be photographed, videotaped, or recorded for Youth & Family Village and Heart & Soul Center of Light ministry-related communications and publications. No, I do not give permission for my child to be photographed, videotaped, or recorded for public or promotional use.

Would you like to make a donation to support YFV?

I am the parent or legal guardian of the child listed on this form. By typing my name below and submitting this form, I confirm that the information provided is accurate to the best of my knowledge and that my typed name serves as my electronic signature.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2026-27 HSCL Youth and Family Village Registration Form

Description

Please Fix the Following