FRC Parental Consent / Release Form
Student Name
*
First Name
Last Name
Student Birth Date
*
-
Month
-
Day
Year
Date
Student Grade
*
Please Select
6
7
8
9
10
11
12
Student Cell Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Church
School
*
Parent Information
Parent 1
*
First Name
Last Name
Parent 1 Email
*
example@example.com
Parent 1 Phone Number
*
Please enter a valid phone number.
Parent 2
First Name
Last Name
Parent 2 Email
example@example.com
Parent 2 Phone Number
Please enter a valid phone number.
Emergency Contact
Other than Parents
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Hospital Insurance?
*
Yes
No
Insurance Company
Policy Number
Policy Holder
Group Number
Primary Care Doctor
Doctor Phone Number
Please enter a valid phone number.
Allergies and Reactions
Other Special Medical Problems we should be aware of:
Name of Participant
*
First Name
Last Name
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Back
Next
Fellowship Reformed Church
Media Release/Consent Form
List names of all students in the same family to which this release applies
*
Date
*
-
Month
-
Day
Year
Date
Signature of Parent/Guardian
*
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Submit
Submit
Should be Empty: