Bridges Community Church - Medical & Liabilities Release Form
In order to keep our students happy and safe at a BCC event, we need some helpful information from you. Please fill out the information below for our records. Please complete ONE form for each student.

IMPORTANT: Forms will need to be updated yearly to ensure we have the most up-to-date information for each student.

Questions? Email Vivian Yasutake at vivian.yasutake@connectbcc.org.

For what area of ministry are you completing this form? *
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Parent / Guardian Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Parent / Guardian Name 2 *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
With Whom Does the Student Live? *
Your answer
Address Where Student Lives (e.g., 123 Main St., Los Altos, CA 94024) *
Your answer
Emergency Contact Name (Other than Parent / Guardian listed above) *
Your answer
Phone Number *
Your answer
Emergency Contact - Relationship to Student *
Your answer
Name of Healthcare Provider and/or Preferred Hospital *
Your answer
Physician Name *
Your answer
Healthcare Provider Address *
Your answer
Health History
Name & dosage of any medication student takes on a regular basis
Your answer
Other Medical Notes
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service