WOW, GEMS & Cadets Registration
2018-2019
Parent's Names *
Your answer
Address *
Your answer
City *
Your answer
Best phone # to reach you *
Your answer
Alternate Phone
Your answer
Family Email Address *
Your answer
Name of church attended, if any
Your answer
Emergency Contact (other than parents) *
Your answer
Emergency Contact Phone *
Your answer
Child #1 First Name *
Your answer
Child #1 Last Name *
Your answer
Child #1 Gender *
Child #1 Birthdate *
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DD
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Child #1 Grade *
If registering for GEMS, what is your daughter's shirt size?
Behavioral Concerns (ADD, ADHD, anxiety, autism, etc.) *
Your answer
Medical Concerns (allergies, medications, dietary restrictions, etc.) *
Your answer
Swimming Restrictions (Grades 2-8 Only)
Your answer
If you are only registering one child, please scroll down to Insurance Information
Child #2 First Name
Your answer
Child #2 Last Name
Your answer
Child #2 Gender
Child #2 Birthdate
MM
/
DD
/
YYYY
Child #2 Grade
If registering for GEMS, what is your daughter's shirt size?
Behavioral Concerns (ADD, ADHD, anxiety, autism, etc.)
Your answer
Medical Concerns (allergies, medications, dietary restrictions, etc.)
Your answer
Swimming Restrictions (Grades 2-8 Only)
Your answer
If you are only registering two children, please scroll down to Insurance Information
Child #3 First Name
Your answer
Child #3 Last Name
Your answer
Child #3 Gender
Child #3 Birthdate
MM
/
DD
/
YYYY
Child #3 Grade
If registering for GEMS, what is your daughter's shirt size?
Behavioral Concerns (ADD, ADHD, anxiety, autism, etc.)
Your answer
Medical Concerns (allergies, medications, dietary restrictions, etc.)
Your answer
Swimming Restrictions (Grades 2-8 Only)
Your answer
If you are registering more than three children, please contact Alecia Jablonski at aleciaj@trinitypella.org.
Insurance Information
If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is participating in an activity. If your child should require medical attention for injuries received or illnesses contacted prior to an activity, please provide us with the necessary information to give him/her proper medical care during his/her time during the church sponsored activity.
Name of Insurance Company (enter 'N/A' if inapplicable) *
Your answer
Name & City of Family Doctor *
Your answer
Trinity Reformed Church Medical & Liability Release Statement
I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the persons listed on this form. In the event I cannot be reached in an emergency during the dates of the activity shown on the permission form, I hereby give my permission to the physician or dentist or other medical personnel selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.

I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Trinity Reformed Church through its accident policy will be used as a backup for what my family’s insurance does not cover.

I understand that all reasonable safety precautions will be taken at all times by Trinity Reformed Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Trinity Reformed Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

Have you read & understood the Trinity Reformed Church Medical & Liability Release Statement? *
Enter your full name & today's date *
Your answer
In what areas are you interested in volunteering in your child's ministry, if any?
Your answer
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