Registration Form Rebelution 2023-2024
Telephone Baptist Church
This 2023/2024 Permission Form & Medical Waiver will apply to all student events, trips and projects from September 1, 2023 through August 31, 2024. In the event that a participant needs medical attention, this waver will provide an adequate and current record of the student's medical information.
Student's Name
*
Birthdate
-
Month
-
Day
Year
Date
Grade
*
Please Select
Pre K
Kindergarten
1st
2nd
3rd
4th
5th
6th
1st Parent/Legal Guardian Name
*
1st Parent's Cell Phone Number
*
Please enter a valid phone number.
2nd Parent/Legal Guardian Name
2nd Parent's Cell Phone Number
Please enter a valid phone number.
Home Phone (landline)
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Communication is through the REMIND APP. Please provide a cell phone number if you would like to receive text messages
Please enter a valid phone number.
Name of Church you attend
1st Emergency Contact's name (other than parents)
*
1st Emergency Contact's phone number
*
Please enter a valid phone number.
1st Emergency Contact's relationship to student
*
2nd Emergency Contact's name
*
2nd Emergency Contact's phone number
*
Please enter a valid phone number.
2nd Emergency Contact's relationship to student
*
Medical information
Physician's Name and Phone Number
List below (or write none) any physical defects or conditions that the student has such as: allergies, asthma, nervousness, headaches, etc.
*
Should the student, at any time, require medical attention, list any special information (or write none) which the physician might require (i.e. allergic to penicillin, rare blood type, etc.)
*
Are the student's immunizations current?
Please Select
Yes
No
Medical Insurance Provider (or write none)
Medical Insurance Phone Number
Please enter a valid phone number.
Policy Number
Is there any additional information we need to know about the student? (or write none)
*
Medical Waiver
I, the parent and/or legal guardian of the student, a minor, hereby acknowledge that said minor is presently under my care, custody and control. I hereby give said minor permission to participate in any and all activities at and with Telephone Baptist Church of Telephone, TX, for which he/she, with my approval, registers to participate. I further expressly grant permission for said minor to participate in all activities while an active participant on trips and church events. In the event there arises an emergency necessitating medical or surgical attention, I hereby consent and give my permission to Telephone Baptist Church of Telephone, TX staff, its representatives, the sponsors, or any attending physicals to make such decisions and to perform such medical treatments and/or surgery upon said minor which may, in their sole discretion, be necessary and proper under the circumstances. I, the undersigned parent and/or legal guardian of said minor, do hereby release, acquit, discharge and covenant to indemnify and hold harmless Telephone Baptist Church of Telephone, TX, its staff and/or representatives, the sponsors, and/or any attending physician from any and all claims, damages, actions, and causes of action of any nature, including but not limited to negligence, damages, and liabilities, arising out of the treatment of any sickness and/or accident, and from financial responsibility for all medical treatment provided during the attendance of any children/youth events. I also assume responsibility for providing and paying for return transportation of said minor from the event location should it be necessary for disciplinary reasons.
*
Photo Waiver
I understand that photos and/or videos may be taken at ministry events and that the photos/videos, may be used by Telephone Baptist Church for ministry information, promotions, etc. I give my permission for Telephone Baptist Church to use photos/videos of my student.
*
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