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>> HeartFlow Youth Ministry Camp Permission Form <<
STUDENT INFORMATION
Student First Name
Student Last Name
Address 1
Address 2
City
State
Zip/Postal Code
Student Phone Number
Student Email
Student Date of Birth
Student Gender
Male
Female
Student T-shirt size
Small
Medium
Large
X-Large
2XL
3XL
PARENT/ GUARDIAN INFORMATION
P/G First Name
P/G Last Name
P/G Home Phone Number
P/G Cell Phone Number
P/G Email Address
EMERGENCY CONTACT
(if parents are unable to be reached)
E.C. First Name
E.C. Last Name
Relation to student:
E.C. Home Phone Number
E.C. Cell Phone Number
MEDICAL INFORMATION:
Insurance Company:
Policy #:
Group #:
Medical Conditions or Allergies: (Please make special note of food allergies)
Medication(s) Currently Being Taken: (Please note medication names, dosage and times taken)
CONSENT INFORMATION
STUDENT CONSENT: I promise to abide by all rules and plans set forth by the leaders of HeartFlow Youth Ministry during the course of this event. Student Digital Signature: (type full name)
PARENT/ GUARDIAN CONSENT: I / we are the legal guardians of the student named above and hereby give my / our permission for the named student to participate in ENGAGE Camp. I understand that in the event of an emergency that the leaders of HeartFlow Youth Ministry will do everything in their power to contact me personally, but that in the event that they are unable to do so, I / we give my / our permission for the leaders to seek necessary medical attention for the student named above. Parent/ Guardian Digital Signature: (type full name)
Submit Registration
