Student Information Form 2023-2024

Ministries student will be involved in:

Sunday School Cadets Gems Youth Group

Student's Name

Birth date

Gender

Address

Student's Phone

Student's Email

Parent/Legal Guardian Information

Parent/Guardian Name

Home Phone

Cell Phone

Parent/Guardian Email

This address will receive a confirmation email

Emergency Contact if Parent/Guardian cannot be reached

Emergency Contact Phone

Helpful Information

Student Allergies and Health Concerns:

Other information regarding your student that would be helpful for counselors/teachers:

Names of any siblings attending:

Insurance Information

Physician

Office Phone

Insurance Carrier

Insurance Policy Number

Waiver

As the parent/legal guardian of this child, I give permission for him/her to participate in any activities pertaining to the Children's/Youth ministries at Harlem Reformed Church. I also release Harlem Reformed Church, their staff and volunteers from any liabilities that could result from unintentional accidents and/or self inflicted harm. I also give permission for him/her to receive medical treatment deemed necessary by appropriately trained medical personnel. I also give permission for the use of photographs in which they are included for church publicity.

I agree

Signed

Date

Student Information Form 2023-2024

Description

Please Fix the Following