Student Information
Name/Date of Activity___________________________________ ____/____/___
Student Name_______________________________________Male___Female___
Birthdate(mm/dd/yy)_______________ Age____ Grade________
Address ____________________________________________________________
City ____________________________________State _________ Zip __________
Home Phone (____) ____-__________Emergency Phone (____) _____-_________
Parent / Guardian ____________________________________________________
Parent E-Mail _________________@________.COM Cell# (___) ____-_________
Amt. Enclosed $_____ Circle Appropriate: Cash Check #____. Full Amt–Dep–Bal?
Health Insurance Co. Name ____________________________________________
Policy # ____________________________________________________________
Please list any allergies or health problems that we should be aware of. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
As a parent or legal guardian, I hereby give my permission for a health care professional to do what is necessary for the health of my child. I give my permission for my child to participate in all activities. I release First Christian Church and its leadership for liability in case of accident or illness. We do support and the student agrees to abide by all regulations and policies.
Signature of Parent / Guardian _______________________________________________ Date ________________
