Mo Ranch 2019
**Registration for your Middle School or High School student to attend Mo Ranch and stay with the other students and FPC Youth leaders. You do not need to fill this out if you have already registered your child to attend Mo Ranch with your family!**
Thursday, July 11 - Sunday, July 14
Drop off at FPC at 9:30am on 7/11!
Last Name of Student *
Your answer
First Name of Student *
Your answer
Gender *
DOB (MM/DD/YYYY), example: 05/01/2000 *
MM
/
DD
/
YYYY
Student's Cell # *
Your answer
School *
Your answer
Grade Level (2018-19) *
Father's Last Name *
Your answer
Father's First Name *
Your answer
Father CELL # *
Your answer
Mother's Last Name *
Your answer
Mother's First Name *
Your answer
Mother CELL # *
Your answer
Father Email Address *
Your answer
Mother Email Address *
Your answer
Emergency Contact (Name & Relationship) *
Your answer
Emergency Contact CELL# *
Your answer
Name of Student's Physician *
Your answer
Student's Physician PHONE # *
Your answer
Allergies & Dietary Restrictions (include details for treatment) *
Your answer
If Student takes any medications, please give Name, Dosage and Time Taken *
Your answer
If Student has had any Mental Health History, please give a brief description here. All information is confidential. *
Your answer
Medical Insurance Company *
Your answer
Medical Insurance Phone # *
Your answer
Medical Insurance Policy # *
Your answer
Medical Insurance Group # *
Your answer
TRAVEL RELEASE - I hereby authorize my child to travel by bus or van with the First Presbyterian Church Youth Leaders from 7/11/19 - 7/14/19 and I give authorization to the adults serving on behalf of FPC Houston to act as my agents. *
MEDICAL RELEASE - In an emergency, I give my permission to any physician, dentist or health care attendant: 1) to secure proper intervention, x-ray examination, medical or surgical diagnosis and treatment, anesthesia, hospitalization, and any other medical attention for my youth; and 2) to communicate with any FPC youth leader accompanying my youth. *
LIABILITY RELEASE - As the parent or legal guardian, I agree to assume and accept all risks and hazards inherent in any FPC Youth Ministry Activity in which my youth participates. I agree NOT to hold First Presbyterian Church of Houston (FPC) or its employees or its volunteer leaders liable for damages, losses, or harm to my youth (including bodily injury or death) or his or her property, including harm resulting from negligence of FPC or negligence of any FPC employee or FPC volunteer leader. *
BEHAVIORAL EXPECTATIONS - My child and I understand that behavioral expectations are laid out to students on the first day of the event and I expect my child to adhere to these expectations throughout the duration of the event. In the case that my child does not adhere to these expectations, FPC Leaders at their sole discretion may determine the appropriate consequences for their behavior, which may include sending my child home (AT MY EXPENSE). I also accept financial responsibility for any damages caused by my child during the course of this event. *
DRUG & ALCOHOL AGREEMENT - My child and I understand that if he or she is caught in possession of drugs or alcohol (including e-cigarettes) during the course of this event, I accept full responsibility for arranging for his or her transportation home and I understand my child will not travel home with the group. *
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