Release Form
Participant Information, Permission, and Medical Release
Student First Name
Your answer
Student Last Name
Your answer
Grade in School
Your answer
Age
Your answer
Gender (for housing purposes)
Your answer
Birthdate | month/day/year
Your answer
Student Email Address
Your answer
Street Address
Your answer
City, State Zip
Your answer
Student Phone
Your answer
1st Parent/Guardian Full Name
Your answer
1st Parent/Guardian Phone
Your answer
1st Parent/Guardian Email Address
Your answer
2nd Parent/Guardian Full Name
Your answer
2nd Parent/Guardian Phone
Your answer
2nd Parent/Guardian Email Address
Your answer
Emergency Contact Full Name
Your answer
Relationship
Your answer
Emergency Contact Phone
Your answer
Date of Last Tetanus Shot | month/year
Your answer
Family Physician
Your answer
Family Physician Phone
Your answer
Medical Insurance Provider
Your answer
Medical Insurance Policy Number
Your answer
Medical Insurance Identification Number
Your answer
Allergies
Your answer
Food Sensitivities
Your answer
Any Special Needs or Restrictions
Your answer
Photographs or Video of My Child
I have legal custody of the minor named on this form and give consent for participation in the activities of the youth programs at Newberg Friends Church, North Valley Friends Church, West Chehalem Friends Church, and 2nd Street Community Church from the date below to July 1, 2017.
Today's Date
Your answer
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