Child Registration Release Form

Student Info

Student's Name

Date of Birth

Grade (or grade entering, if summer)

Student 2 Name

Date of Birth

Grade

Student 3 Name

Date of Birth

Grade

Student 4 Name

Date of Birth

Grade

Contact Info

Child's Home Address

City

State

Zip Code

Parent/Guardian's Name

Primary Phone

This address will receive a confirmation email

Is email a good way to communicate with you?

Yes No

Second Parent/Guardian's Name

Primary Phone

Insurance Info

*Insurance information is only needed for grades 5-12

Insurance Company

Policy Number

Group Number

Other Info

Is your child in good health and able to participate in all activities

Yes No

If "no," please explain briefly

Does your child have allergies to medication or food?

Yes No

If "yes," please list allergies

Signature

By typing my name below, I am signing this consent form. In doing so I hereby certify that the above information is correct and I grant my permission for the release of medical records in the case of accident during an activity. In case of medical emergency, I understand that every effort will be made to contact the child's parent/guardian. In the event I cannot be reached, I hereby grant permission for the adult leaders of Vriesland Reformed Church to obtain emergency medical care and proper treatment for my child named above, at my expense. Parent/Guardian agrees on behalf of both parents/guardians and the child, to indemnify, defend, and hold harmless the ministry, and its agents, employees, volunteers, and other representatives for injury arising while my child is in their care. I also give permission for the use of photographs and videos including my child to be used in church publicity.

Parent/Guardian Electronic Signature

Date

Description

Please fill out this form and click submit.

Child Registration Release Form

Description

Please Fix the Following