FBC Youth
Registration Form
PARENT / GUARDIAN INFO
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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STUDENT'S CONTACT INFO
How many students will be attending FBC Youth?
*
Please Select
1
2
3
1st Student's Info
Name
*
First Name
Last Name
Health Card
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
2nd Student's Info
Name
*
First Name
Last Name
Health Card
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3rd Student's Info
Name
*
First Name
Last Name
Health card
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
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STUDENT MEDICAL NEEDS
Do any of these students have any severe allergies? (bee stings, food, etc.)
*
Yes
No
Please explain
Are any of these students bringing any medication with them? (inhaler, Ritalin, etc.)
*
Yes
No
Please explain
Do any of these students have any physical, emotional, mental, or behavioral concerns or limitations that our staff should be aware of?
*
Yes
No
Please explain
Emergency Contact - another adult who can be contacted in the event of an emergency and the parent/guardian can not be reached.
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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CONSENT
I consent to having my youth’s picture to be taken and posted online or used in material produced by the church.
*
Yes
No
I consent to allowing youth leaders to drive my students to events off the property of FBC Collingwood.
*
Yes
No
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ACKNOWLEDGMENT
Signature
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