Northwest Presbyterian Church

Registration Form
Attendee Name * First Last
Please insert your child's name as it will appear on his/her name badge.
Current Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Attendee's Birthdate * MM / DD / YYYY
Age as of July 16, 2012 *
Enter a number between 1 and 14.
School Grade Just Completed *
Primary Parent or Guardian Name * First Last
Please insert your child's name as it will appear on his/her name badge.
Primary Parent or Guardian Phone * ### - ### - ####
Primary Parent or Guardian Email *

We take your privacy very seriously and do not distribute any personal information in any way.
Other Parent or Guardian Name First Last
Please insert your child's name as it will appear on his/her name badge.
Other Parent or Guardian Phone ### - ### - ####
Other Parent or Guardian Email

We take your privacy very seriously and do not distribute any personal information in any way.
Emergency Contact * First Last
Please insert your child's name as it will appear on his/her name badge.
Emergency Contact Phone * ### - ### - ####
Emergency Contact Email

We take your privacy very seriously and do not distribute any personal information in any way.
By choosing below, I hereby GRANT or DO NOT GRANT permission for Northwest Presbyerian Church to use pictures of my child on their website for informational or promotional purposes. *
GRANT DO NOT GRANT
Medical Release Form

Event: Northwest Presbyterian Church SonRise National Park VBS 2012

I/we the undersigned parent(s) or guardian(s) of the child listed above, a minor, do hereby authorize the volunteers of Northwest Presbyterian Church, Inc. as agents for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or sugeon in an approved emergency clinic or hospital.
I further release from any liability Northwest Presbyterian Church, Inc. and any of its ministries, leaders, or volunteers in the event of an accident en route, during, and returning from the above mentioned event.
Date Signed * MM / DD / YYYY
Parent/Legal Guardian FULL LEGAL NAME *

By inserting my FULL LEGAL NAME here, I am digitally signing this Medical Release Form.
LAST 4 DIGITS OF SS NUMBER *
Must be between 4 and 4 characters. Currently Used: 0 characters.

BY INSERTING THE LAST 4 DIGITS OF MY SOCIAL SECURITY NUMBER, I AM VERIFYING MY DIGITAL SIGNATURE ABOVE.
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Number: Home * ### - ### - ####
Emergency Number: Work * ### - ### - ####
Health Insurance Company *
Policy or Group Number *
If parent/legal guardian in not available in an emergency, contact * First Last
Emergency Contact Phone * ### - ### - ####
Please list any allergies. Include medications, foods, etc.
Does your child have any medical or special needs, including medications currently being used?
Yes No
If yes, please explain
Doctor's Name *
Doctor's Phone * ### - ### - ####
Dentist's Name
Dentist's Phone ### - ### - ####
Date of last tetanus shot MM / DD / YYYY
Date of Birth MM / DD / YYYY
Do Not Fill This Out

Northwest Presbyterian Church

Registration Form

Medical Release Form