2017 College Road Medical/Discipline/Media Release Form
This form is required for any participant on any church sponsored trip, function or event. This form will be used for all trips or events during that particular year. If there are changes throughout the year, it is the participants responsibility to complete an updated form
Participant's Last Name *
Your answer
Participant's First Name *
Your answer
Birth Date *
(Example: 12/14/1983)
Your answer
Age *
Your answer
Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Contact Phone Number *
Example: (555)555-5555
Your answer
Cell Phone Number (If Different from Contact Phone Number)
Example (555)555-5555
Your answer
Cell Phone Carrier *
Example: (AT&T, Sprint, T-Mobile, Verizon)
Your answer
May we communicate with you via text messaging *
Email Address *
Your answer
If Participant is under 18 years of age, please fill out the information below
Father/Guardian's Name
* Required If participant is under 18 years of age
Your answer
Father/Guardian's Work Phone Number
Example: (555)555-5555
Your answer
Father/Guardian's Cell Phone Number
Example: (555)555-5555
Your answer
Cell Phone Carrier
Example: (AT&T, Sprint, T-Mobile, Verizon)
Your answer
May we communicate with you via text messaging
Mother/Guardian's Name
* Required if participant is under 18 years of age
Your answer
Mother/Guardian's Work Phone Number
Example: (555)555-5555
Your answer
Mother/Guardian's Cell Phone Number
Example (555)555-5555
Your answer
Cell Phone Carrier
Example: (AT&T, Sprint, T-Mobile, Verizon)
Your answer
May we communicate with you via text messaging
Please provide the information for two emergency contacts
Emergency Contact 1
Name *
Your answer
Relationship *
Your answer
Contact Phone Number *
Example (555)555-5555
Your answer
Emergency Contact 2
Name *
Your answer
Relationship *
Your answer
Contact Phone Number *
Example (555)555-5555
Your answer
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