Senior High Kick Off Registration
Student First Name *
Your answer
Student Last Name *
Your answer
Student Cell Phone *
Your answer
Student Grade in the Fall *
Parent Name *
Your answer
Parent Cell Phone *
Your answer
Parent Email *
Your answer
Home Address *
Your answer
Zip Code *
Your answer
Insurance Provider *
Your answer
Policy Holder *
Your answer
Policy Number *
Your answer
Any Allergies or Conditions *
Your answer
Liability Information
The Staff and Chaperones of First Presbyterian Church Glen Ellyn have my permission to seek medical care for my child(ren) in the case of an injury or accident. We will make every effort to contact you, but in the event I cannot be reached, the medical professionals have my permission to treat my child(ren) as deemed necessary.
I have read and agree to the above stated conditions for my students participation. *
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