Event Name

Student Name *

First Name

Middle

Last Name

Student Address *

Address Line 1

Address Line 2

City

State

Postal Code

Student Home Phone

Student Cell Phone

Student Email

Student Birthday*

Student Gender*

Parent/Guardian Name *

First Name

Middle

Last Name

Parent/Guardian Email

If the Parent/Guardian named above is not available, in case of emergency, notify:

Emergency Contact #1 *

First Name

Middle

Last Name

Emergency Contact #1 Phone*

Emergency Contact #2 *

First Name

Middle

Last Name

Emergency Contact #2 Phone*

Name of Physician*

Physician Phone*

Health Insurance Carrier

Policy #

Is the student currently taking any medications? Yes
No

List Medications

List Allergies (food, medicines, insects, plants, etc.)

Medical conditions to be aware of:

Do we have permission to give your student over-the-counter pain relievers if needed as evidenced by student's statement or behavior?* Yes
No

I do hereby release, forever discharge and agree to hold harmless South Haven Christian Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in Church Activities. The undersigned further hereby agrees to hold harmless and reimburse said church, its directors, employees, chaperones, and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto. The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless said church, its directors, employees, chaperones, and agents from failure to act on the part of those chosen to administer medical care on behalf of the participant. For valuable consideration received, I hereby irrevocably grant to South Haven Christian Church the worldwide, royalty-free, right to use the participant’s name, voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial. I understand that my participation makes me eligible to receive information and updates regarding ministry successes and opportunities.

eSignature box*

By typing your name in this box, you are confirming that all the information submitted here is true and accurate, that you have read this entire form and you are giving your permission for your student to participate in South Haven Christian Church activities.