Activity/Event
Student Name
Payment Type
Student Home Phone
Student Cell Phone
Grade
Gender
Age
Birthday
Address
City
State
Zip
Parent/Guardian Name
Home Phone
Other Phone
Friend you want to be with?
T-Shirt Size
If you attend church, where?
Member at that church?
Have you turned your life over to Christ?
Is student taking medicine? (If so, explain)
Does student have allergies? (If so, explain)
Emergency Contact Name
Emergency Contact Phone
Insurance Company
Identificaton Number
Doctor's Name
Doctor's Phone
Hospital Preference
I hereby consent for my child to be treated by a qualified physician or nurse if the occasion occurs
I also give my consent for him/her to be admitted to the hospital if necessary.
Parent Guardian Initials (This serves as your signature)
Please answer the simple math question below to submit the form.
2 + 2 =