GNC Registration and Medical History Form

Good News Club Registration and Medical for After School Club Students in Southern New Mexico 2025/2026

Please fill out, sign & date this form so we can meet any special needs your child has & so we have enough information in case of an emergency. Please fill out one per child/sibling.
WHAT IS A GOOD NEWS CLUB??
What School Does your Student Attend?*
Student Name*

First NameMiddle NameLast Name
Student's Gender *
Parent1/Guardian1 *

First NameLast Name
Parent1/Guardian1 Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
Parent1/Guardian1 Email *
example@example.com
Parent2/Guardian2*

First NameLast Name
Parent2/Guardian2 Email*
example@example.com
Parent2/Guardian2 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Student Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Child’s name) First Name* Last Name* is allowed to attend the Good News Club at (Elementary School) name of elementary school *
(day of the week) there is a full day of school.. I understand it is my responsibility to pick up my child at 4:30 pm and failure to do so will jeopardize my child’s continued participation.
Signature*
Child's School:           *

Grade:     *
Birth Date:      *
Childs Age:      *

Any Security/Custody Issues with this child?

List any special needs (ADD, Asperger's, Dyslexia etc.)

Child's allergies (peanuts, chocolate, etc.)      *

Emergency Contact 1:                  First Name*   Last Name*

Emergency Contact 2:               First Name   Last Name

PERMISSION FOR PICK-UP—in addition to those listed above, the following people are
allowed to pick up my child:
First Name*   Last Name*   Phone:   Area Code*   Phone Number*
First Name*   Last Name*   Phone:   Area Code*   Phone Number*

Photography and Video Release

Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with
photos or videos. I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries, and successors, and
assign the unqualified right to the ownership, use, and proceeds of all photographs or video of me or
my minor child, without reservation or limitation, including the use of photographs or video of me or my minor child for, but not limited to, advertising, educational, and promotional purposes.

Child's Printed Name:   First Name*   Last Name*   Date*
Parent/Guardian Printed Name:   First Name*   Last Name*
Signature*
Good News Club Medical History Form

Please fill out, sign & date this form so we can meet any special needs your child has & so we have enough information in case of an emergency. Please fill out one per child/sibling.
*Insured Parent’s Work Phone #
(CEF’s insurance pays only for accident expenses not covered by your family insurance & does not cover illness, such as colds, flu, appendicitis, etc.)

Family Doctor Name:
* Address Street Address* Address Line 2* City* State* Zip*
Dr. Phone Number: Phone Number*
Is your Student Currently taking any Medications?*

YESNO
IF "YES" please list the Medication*
Check the conditions that apply to your child:*

AsthmaCardiac DiseaseHypertensionHas your child had a tetnus shot?Ear AchesHyperactivityStomach AchesCancerDiabetesEpilepsySleep WalkingHay FeverHomesicknessOtherNo my Child has none of these
Does your Child have allergies?*
IF "YES" Please list the allergies below*
List heath or other conditions that would limit the child’s participation in CEF® activities*
In addition to prescribed medications, my child has my permission to receive the following over-the-counter drugs: (circle the drugs you approve) Tylenol, Advil, Cough Syrup, Stomach antacid, Decongestant, Antihistamine, Other *
I hereby release Child Evangelism Fellowship® Inc., its staff, board members, & agents from responsibility & liability for any injury or illness that my child may sustain during the above-mentioned CEF® program. I hereby permit for my child to receive medical treatment in the event of an emergency. I expect to be contacted as soon as possible.*

MonthDayYear
Date
Parent's Signature *
Should be Empty:

Good News Club Registration and Medical for After School Club Students in Southern New Mexico 2025/2026

Good News Club Medical History Form