Created to Create Registration Page Extended - Calvert Grace Community Church

Parent Name(Required)

First Last

Email(Required)

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Photograph Consent

I give my permission to have my child photographed.

Number of Child

Please enter a number from 1 to 3.

Consent

Check here if you are interested in being a parent volunteer and someone will contact you:

Child 1 - Medical Release Portion

Child's Name

First Last

Child's Birthdate

Consent(Required)

I give permission for the adult leaders from Calvert Grace to seek medical treatment for my child. In the event of an emergency, I consent for my child to receive such medical treatment and/or surgical procedures deemed necessary by medical personnel. I hold harmless and fully and forever release and discharge Calvert Grace, all officers, agents and volunteers and or employees or staff of Calvert Grace from any and all claims, demands, rights of action, present or future, whether the same be known, anticipated or unanticipated, resulting from, or arising out of, or incident to, the providing of this medical assistance. I assume liability for any medical expenses involved. The insurance coverage (if any) that we carry will be the primary coverage for my child. I understand that every reasonable effort will be given to contact me as soon as possible should an emergency arise. Check box that you have read and agree.(Required)

Health Conditions

Allergies

Date of Last Tetanus Shot

Dietary Restrictions

Insurance Company, Group #, ID # Policy Holder's Employer

Parents Name, address, phone number

Emergency Contact Name, address, phone number

Child 2 - Medical Release Portion

Child's Name

First Last

Child's Birthdate

Consent(Required)

Health Conditions

Allergies

Date of Last Tetanus Shot

Dietary Restrictions

Insurance Company, Group #, ID # Policy Holder's Employer

Parents Name, address, phone number

Emergency Contact Name, address, phone number

Child 3 - Medical Release Portion

Child's Name

First Last

Child's Birthdate

Consent(Required)

Health Conditions

Allergies

Date of Last Tetanus Shot

Dietary Restrictions

Insurance Company, Group #, ID # Policy Holder's Employer

Parents Name, address, phone number

Emergency Contact Name, address, phone number

Signature(Required)

By signing this document, I certify all of the above information is true and accurate. I agree to the stipulations above in the event of a need for medical treatment. I have legal custody of the child listed on this form. This release shall be in effect during the times that the above-named minor is in the care and custody of Calvert Grace Community Church and shall include but not be limited to transportation to and from activities sponsored by Calvert Grace.

Name

This field is for validation purposes and should be left unchanged.

Child 1 - Medical Release Portion

Child 2 - Medical Release Portion

Child 3 - Medical Release Portion

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Child 1 - Medical Release Portion

Child 2 - Medical Release Portion

Child 3 - Medical Release Portion

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