Bethel CRC GEMS Registration Form
Email address *
Child's Name *
Your answer
Current Grade *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Parent(s) or Guardian(s) Name(s) *
Your answer
Address (City & Zip Code) *
Your answer
Cell Phone (include name and phone number) *
Your answer
Home Phone
Your answer
Email Address *
Your answer
In case of emergency provide a second emergency contact (Name & Phone Number) *
Your answer
What is your preferred method of communication? *
Family Doctor *
Your answer
Doctor's Phone Number *
Your answer
Insurance Provider *
Your answer
Policy # *
Your answer
Does your child have any of the following? (check all that apply)
If you check any of the boxes above please give details.
Your answer
In case of medical emergency, I hereby give permission to the attending leader to seek medical attention as needed for the child named above. It is understood that all effort will be made to contact the parent/guardian first. *
I do hereby give the child named above permission to attend and participate in the various activities and functions performed by Bethel CRC GEMS. At times, this will require travel to/from activities with a leader. I hereby give my child permission to travel in a vehicle with an adult leader. *
I also understand that in case of an accident or injury, etc. to my/our child, the Bethel CRC GEMS organization, Bethel Christian Reformed Church, and the counselors or leaders will not be held liable. *
Release of Photographs and Videos
Confidentiality of information is of utmost importance to Bethel Christian Reformed Church, which offers and supports the Bethel CRC GEMS program. At times, photographs and videos are used to promote Bethel CRC's GEMS at displays or on the church's website. Names will not be used, just photographs.
We request your permission to use photos or videos that may include your child without names identifying the child for these purposes. *
I also understand that this consent will remain in effect until a written request to revoke consent is received by Bethel GEMS. *
Please type your FIRST and LAST name and DATE *
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service