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ASCENT 2017
REGISTRATION
Child's Name *
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Grade *
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Birthdate *
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Address *
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Parent's Name (Legal Guardians) *
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Relation *
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Phone *
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*
Email *
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Emergency Contact *
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Relation *
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Phone *
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*
Insurance Number *
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Provider *
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Provider Phone *
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Primary Doctor *
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Phone *
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Health Concerns and/or Medications *
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This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Calvary Wesleyan Church and its staff of any liability against personal losses.
I, the undersigned, willingly allow my son/daughter _____________________________ to participate in events/programs organized by CWC Students. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate and active for any care my child may require.
CHILD'S NAME *
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AS THE PARENT OR LEGAL GUARDIAN, BY TYPING YOUR NAME BELOW, YOU ARE SUBMITTING AN ONLINE SIGNATURE AND AGREEING TO THE ABOVE STATEMENT OF CONSENT *
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