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Student Life Registration/Health/Liability 2018/2019
I hereby register and give consent for my child to attend and participate in any event or activity, or meeting on campus or off provided by, sponsored by, or attend by Calvary Church Student Life and its leaders from Sep 1, 2018 - Aug 31, 2019
Student Name *
Your answer
Gender *
Required
Street Address *
Your answer
Town *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Your answer
Email *
Your answer
Cell Phone
Your answer
Other Phone
Your answer
Tell us about yourself (what you like to do, sports, hobbies, music, fav TV show, video games, etc!) *
Your answer
Parent/Guardian Name #1 *
Your answer
Relationship *
Street Address *
Your answer
Town *
Your answer
Email *
Your answer
Cell Phone *
Your answer
Other Phone
Your answer
Parent/Guardian Name #2
Your answer
Relationship
Street Address
Your answer
Town
Your answer
Email
Your answer
Cell Phone
Your answer
Other Phone
Your answer
EMERGENCY CONTACT Name #1 *
Your answer
Relationship *
Cell Phone *
Your answer
Other Phone
Your answer
EMERGENCY CONTACT Name #2
Your answer
Relationship
Cell Phone
Your answer
Other Phone
Your answer
INSURANCE COMPANY *
Your answer
Phone Number
Your answer
Policy Number *
Your answer
Group Number
Your answer
Policy Holder Name *
Your answer
PRIMARY CARE PHYSICIAN NAME *
Your answer
Phone Number *
Your answer
Medical Info (allergies - including food, health problems, medications, or other health concerns) *
Your answer
Prescriptions
Your answer
What, if any, pain medication can your child take? (Tylenol, Advil, Aspirin, etc.)
Your answer
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