Children & Youth Registration Form - Covenant CRC 2017-2018
***Please complete ONE form PER child.
Child's First Name *
Your answer
Child's Last Name *
Your answer
Nickname
Your answer
Date of Birth *
MM
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DD
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YYYY
Age *
Your answer
Grade *
Your answer
Child's School *
Your answer
Child's Church *
Your answer
Home Address *
Your answer
Mother's First Name *
Your answer
Mother's Last Name *
Your answer
Mother's Best Phone # *
Your answer
Father's First Name *
Your answer
Father's Last Name *
Your answer
Father's Best Phone # *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone # *
Your answer
Doctor Name *
Your answer
Doctor Phone # *
Your answer
Insurance Company *
Your answer
Insurance Policy # *
Your answer
Please list any medical conditions, allergies, or health concerns of which we should be aware: *
Your answer
Please list any special learning needs and/or recommendations for making Covenant Children's Ministries safer and more effective for your child: *
Your answer
Sunday Mornings
Please mark the ministries your child will be attending: *
Required
Sunday Evenings
Please mark the ministries your child will be attending: *
Required
Wednesday Events
Please mark the ministries your child will be attending: *
Required
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Covenant Christian Reformed Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Covenant Christian Reformed Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its Pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Covenant Christian Reformed Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damage arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further I/we affirm that the health insurance information provided is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Ministry Leader.
Student Name *
Your answer
Student Understands and Agrees to Terms *
Required
Date *
MM
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DD
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YYYY
Parent/Guardian Name *
Your answer
Parent/Guardian Understands and Agrees to Terms *
Required
Date *
MM
/
DD
/
YYYY
To help our Middle and High School leaders better communicate with your student, please fill out the following information:
(Optional, but greatly desired.)
Student Cell # and Provider (Verizon, AT&T, etc)
Your answer
Student Email Address
Your answer
Media Release
I give permission for Covenant CRC to use my child's picture on their website, social media sites, and for media releases (web & print) in which to advertise a church event.
Parent/Guardian Name *
Your answer
Date *
MM
/
DD
/
YYYY
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