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 *
Your answer
Gender *
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Current Grade *
Student Shirt Size *
Student Phone Number *
Your answer
Student Email
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Family Contacts
Emergency Contact 1 - Name *
Please give your name and relationship to student - Jane Doe, Mother
Your answer
Emergency Contact 1 - Phone Number *
Your answer
Emergency Contact 1 - Email *
Your answer
Emergency Contact 2 - Name *
Please give the name and relationship to student - John Doe, Father
Your answer
Emergency Contact 2 - Phone Number *
Your answer
Emergency Contact 2 - Email *
Your answer
Other Emergency Contact
Your answer
Medical Information
Physician's Name and Phone Number
Your answer
Insurance Company and Policy Number *
Your answer
Known Allergies *
Your answer
Current Medications *
Your answer
Health Problems *
Your answer
Information Updates or Changes
If any of the above information changes during the current school year, I will notify the Student 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 *
Your answer
Email Address *
Your answer
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