Student's Full Name (First, Middle, Last)
Address (Please include City, State, and Zip Code)
Date of Birth (MM/DD/YYYY)
Please Select the Grade You Will Be ENTERING at the Start of the 2018-19 School Year
What School Will You Be Attending?
Student's Cell Phone #
In Detail Below, Please List Any and ALL Allergies
Medical Insurance Company
Mother's Full Name
Mother's Best Contact #
Father's Full Name
Father's Best Contact #
Full Name of Emergency Contact
Best # to Reach Emergency Contact Person
Physician's Office #
Dentist's Office #
If Necessary, Describe in Detail Any Physical and/or Psychological Ailment, Illness, Limitation, Disability, or Condition of Which the Staff Should be Aware; and Any Action Required on Account Thereof. Include Names of Medications and Dosages That Must Be Taken.
Does Your Child Suffer From, or Has Ever Experienced, or is Being Treated Currently for Any of the Following:
Date of Student's Last Tetanus Shot (MM/DD/YYYY)
Should This Student's Activities Be Restricted For Any Reason?
If YES to the Previous Question, Please Explain Why and How Their Activities Should be Restricted
Please Mark Below Your Agreement to Follow Our Rules of Conduct (Mark Each Box)
By continuing you, the parent(s)/guardian(s) of the student listed above agree to the following statement:
My son/daughter has my permission to attend all youth activiites or trips sponsored by Plymouth Avenue Christian Church (hereinafter the "Church") from August 1, 2018 to September 1, 2019. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child's involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home AT MY OWN EXPENSE should they become ill or if deemed necessary by the Student Ministries staff.
In order to complete this form, I understand that I MUST come to Billy and sign a copy.
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