Wilcrest Student Information Form
Hello! You are receiving this form since you have one or more students in the Wilcrest Student Ministry. The purpose of this form is to capture basic information of students and parents one time during the current school year instead of filling this information out for every event. For specific events, we will still require a signed permission slip from parents or guardians. This Information Form will be renewed on an annual basis or whenever information may change during the school year.

For Required (*) fields, please enter carefully or enter 'None' if it does not apply to your student.
Student Information
Student Name *
Gender *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Current Grade *
Student Shirt Size *
Student Phone Number *
Student Email
Street Address *
City *
Zip Code *
Family Contacts
Emergency Contact 1 - Name *
Please give your name and relationship to student - Jane Doe, Mother
Emergency Contact 1 - Phone Number *
Emergency Contact 1 - Email *
Emergency Contact 2 - Name *
Please give the name and relationship to student - John Doe, Father
Emergency Contact 2 - Phone Number *
Emergency Contact 2 - Email *
Other Emergency Contact
Medical Information
Physician's Name and Phone Number
Insurance Company and Policy Number *
Known Allergies *
Current Medications *
Health Problems *
Information Updates or Changes
If any of the above information changes during the current school year, I will notify the Youth Pastor as soon as possible. *
Required
Release of Liability Declaration
By entering my name below and submitting this form, I give my authority and consent to Wilcrest Baptist Church sponsors/leadership to seek a doctor or qualified person to provide emergency medical treatment to this student in the event they become ill or injured while traveling and participating in Student Ministry activities. I do release, acquit, discharge, and covenant to hold harmless Wilcrest Baptist Church (10800 Sharpview Dr. Houston, TX 77072) its sponsors and representatives from any and all actions, causes of actions, damages, and/or liabilities arising from the medical treatment of any sickness or injuries from accident incurred by this student during these activities. *
Required
Signature of Consent
Please enter the Complete Name of Consenting Parent/Guardian *
Email Address *
Submit
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