GRACE PRESBYTERIAN STUDENT MINISTRY REGISTRATION
2018-2019
Student Name *
Your answer
Parent Name(s)
Your answer
Email Address(es) *
Your answer
Address and Phone Number *
Your answer
Emergency Contact Information (Please provide 2, at least one who is not a parent) *
Include Name, Relation, Address, and Phone Number
Your answer
My student resides with: *
Student's School and Grade *
Your answer
Student's Sports/Extracurriculars *
Your answer
Insurance Information *
Include Provider, Policy Holder's Name/Employer/Date of Birth, Policy and Group Number, Company Address
Your answer
Dietary restrictions *
Your answer
Allergies *
Your answer
Medical Conditions and Medications *
Your answer
Does Grace Pres have permission to administer OTC medicines in the event they're needed? If only certain ones are allowed, use other option and tell us more! *
Does Grace Pres have permission to photograph and/or video your student and publish these photographs and/or videos in promotional materials and social media? *
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