HEIRSPACE Enrollment Form

HEIRSPACE Enrollment
Child's Information

Please fill out a form for EACH child.
Name of Child *

First NameLast NameSuffix
Please select previously completed grade *
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the child have any allergies, chronic illness, or medical conditions? *
Please describe below each condition
Please include name of each child with respective medical conditions.
Does the child above need special accommodations or have a disability? *
Please describe below each condition
Please include name of each child with respective accommodation or disability.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the Christian Covenant Fellowship of Ministries during the selected Youth Conference times.
Emergency Information & Liability Waiver

In the unlikely event of a medical (or other) emergency the parent or the responsible adult listed will be contacted. In the event that the parent/guardian nor the responsible adult is not available, and/or if the CCFM Heir Space Staff decides that your child is in imminent medical danger, the local medical emergencies will be contacted to escort your child with an adult to a medical treatment facility.

In the event that a medical (or other) emergency should occur, neither the Christian Covenant Fellowship of Ministries, The Door of Hope Christian Church, SHERec, Florence Center, nor any of the CCFM Bishops, Pastors, churches, or volunteers, nor anyone authorized/utilized by the aforementioned, assume any responsibility for any debt, liability, or other consequence that occurs as a result of the incident or intervention.

By signing this form, I state that I have read and agree with the provisions above.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

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HEIRSPACE Enrollment

Child's Information