[2019 SST] Central Valley SST Registration – YP Sisters
Email address *
Student Information
Full Name *
Your answer
Gender *
Date of Birth *
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Grade in Fall 2019 *
Locality *
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Student Phone *
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Student Email
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Home Address *
Your answer
Parent/Guardian Information
Parent/Guardian Full Name *
Your answer
Parent/Guardian Email *
Your answer
Secondary Email (optional)
Your answer
Parent/Guardian First Phone Contact *
Your answer
Parent/Guardian Second Phone Contact *
Your answer
Emergency Contact Name
other than above listing
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Emergency Contact Phone *
Your answer
Medical Information
This information is kept confidential.
Health Insurance Company & Plans *
Your answer
Policy Number *
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Date of Last Tetanus Shot
If you have not had a tetanus shot in the last 10 years, we strongly urge you to get one prior arrival to this event.
MM
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DD
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YYYY
Is your child on any medications? *
If "Yes," please give details in the following question.
Medication and dosage
Your answer
Does your child have food allergies? *
If "Yes," please give details in the following question.
Food Allergies and Reactions
Your answer
Is your child allergic to medications? *
If "Yes," please give details in the following question.
Medicine Allergies
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Does your child have any medical limitations? *
For example, physical limitation, bed wetting, etc. Please list them below that may be important in the care of your child. If "Yes," please give details in the following question.
Medical limitation
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Comments, Questions, or Concerns
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Student-Parent Agreement Statement
By clicking "Yes" below, I am going to the Summer School of the Truth with an open and willing heart, a proper attitude, and agree to take seriously the Truth Lessons that are going to be given. I agree to abide by all the rules and regulations, follow the Summer School schedule, and cooperate with the serving ones in all the Summer School activities. I have read and agree to the dress code. *
Parent Release Statement
By clicking "Yes" below, I, as Parent/Legal Guardian of the student listed on this form, acknowledge that: The student listed on this form has my permission to participate in the 2019 Summer School of the Truth at Alpha House that will be held at Alpha House (or the church in Sacramento Meeting Hall) from July 25 to Aug 3, 2018. As the parent or legal guardian of this child, I hereby release the 2019 Summer School of the Truth, the Church in Sacramento and the participating churches and its members, and any person(s) designated by the church to serve in the activities mentioned above, from any financial obligation(s) resulting from any accident or injury that may occur to my child during the time period mentioned above. I also give my permission for my child to attend the 2019 Summer School of the Truth and allow designated serving ones to provide transportation to, during, and from the 2019 Summer School of the Truth and for other related purposes, and to provide emergency medical treatment to him/her in case of injury or illness en route to, during, or from the 2019 Summer School of the Truth. *
By clicking "Yes" below, I as Parent/Legal Guardian of the student listed on this form, authorize the person who bears this note, in the event of an emergency and if contact cannot be made with myself, under section 25.8 of the California Civil Code, to consent to any X-ray examination, anesthetic, hospital or medical treatment for the student listed on this form which is deemed advisable by and to be rendered by or under the supervision of a physician licensed under the provisions of the Medical Practice Act in which stated treatment is rendered. I accept the cost of any such treatment. *
By typing your name below, you certify you are the Parent/Legal Guardian of the child listed on this form and that you acknowledge and accept all responsibilities outlined in this form. *
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