MEMBER INTAKE FORM

Medical Information
Allergies (food, medication, other)
Current Medications
Medical Conditions
Doctor’s Name & Phone
Consent & Liability Waiver

I, the undersigned parent/guardian, give permission for my child to participate in programs and activities with Dwelling Refuge. I understand that while reasonable precautions will be taken, Dwelling Refuge, its staff, and volunteers are not liable for any injury, accident, or illness that may occur.
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Photo/Video Release

I give permission for photos/videos of my child to be taken during activities and used for Dwelling
YesNo
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Transportation Consent

I give permission for my child to be transported by Dwelling Refuge staff or volunteers for events, outings, or emergencies.
YesNo
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Faith & Values Agreement

Dwelling Refuge is a faith-based nonprofit that incorporates Christian values, spiritual growth, and mentorship. By signing, I acknowledge and agree to my child’s participation in faith-based activities.
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Medical Information