Nexus & Ignite Registration Form 2025-2026

Join the fun! Nexus Starts Wednesday, September 3, 2025!

Ignite is for children ages 6-9 (roughly grades 1-3) is joining Nexus! Nexus for ages 9-12 (about grades 4-6) continues this year.

Both groups will have games, snacks, and a lesson each week. We will connect the moral truths of proverbs to Jesus from whomtrue wisdom comes.

Parent/Guardian Information

Name

This address will receive a confirmation email

Phone

Address

Relationship to the child(ren).

Child #1 Information

Name

Birthdate

Grade

Medical or other information we need to know. (Please include any food allergies.)

Child #2 Information

Name

Birthdate

Grade

Medical or other information we need to know. (Please include any food allergies.)

Child #3 Information

Name

Birthdate

Grade

Medical or other information we should know. (Please include any food allergies.)

Child #4 Information

Name

Birthdate

Grade

Medical or other information we should know. (Please include any food allergies.)

Emergency Information

Emergency Contacts (Other than listed above.) Names & Phone numbers

Physician Name:

Physician Phone Number:

Emergency Authorization

I hereby authorize First United Presbyterian church leaders/staff to act on my behalf when I cannot be contacted, IN CASE OF AN EMERGENCY, resulting in the need of medical attention for my son’s/daughter’s named above. I also agree to not hold First United Presbyterian Church, Moline, IL liable for any incident that may result from participation in any of our activities or events, as a result, of my child's participation in its activities. Furthermore, I agree to reimburse First United Presbyterian Church, Moline, IL for any medical expenses.

Electronic Signature*

*By entering my name above, I am providing my digital signature for Emergency Authorization on this form.

Other Information

Dismissal Information: Who may pick up your child(ren) at the end of Nexus each week?

Does your family attend church? If so, where?

If your child(ren) are visiting our church, who are they a guest of?

Permission of Photography

May we have permission to photograph your child(ren)?

Yes No

May we have permission to use your child(ren)'s photograph without a name attached on promotional materials, including but not limited to, social media or other electronic communication?

Yes No

I further understand that if I do not wish for my child(ren) to be photographed, it is my responsibility to notify the Nexus Coordinator.

Electronic Signature*

*By entering my name above, I am providing my digital signature for Permission of Photography on this form.

Consent to Receive Text Messages

I consent to receive pertinent ministry related messages such as cancellations or special events from First Pres Moline.

Yes No

Nexus & Ignite Registration Form 2025-2026

Description

Please Fix the Following