Student Registration Form

Student Registration Form

2026-2028 School years
Parent/Guardian Name

First NameLast Name
Relationship to student:
Parent/Guardian email address
example@example.com
STUDENT INFORMATION
Student Name

First NameLast Name
Student Email address
example@example.com
Student Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Grade
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE AND MEDICAL INFORMATION
Insurance Name
Insurance Policy #
Medical Note
Please note allergies, medications, and any other medical considerations. Please list any dietary restrictions as well.
To Whom It May Concern:

The undersigned does hereby give permission for our (my) child, to attend and participate in any activities planned and sponsored by the Sabina Church of Christ during the time period stated above. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, or surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hosptial. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or othersie, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities by the Sabina Church of Christ.
Signature
I grant consent to the use of photographs/videos of our (my) student taken during the year for publicity and promotional purposes (including publications, presentations, internet or other media sources).
Signature
I consent to receive communication from the church youth ministry via:
I consent for my student to receive communication from the church youth ministry via:
STUDENT CONDUCT EXPECTATIONS
Students participating in youth ministry activities are expected to:
- Respect leaders/sponsors and other students
- Follow church safety policies
- Avoid inappropriate language or behavior
- Follow instructions during activities and trips
Failure to follow expections may result in parents/guardians being contacted or removal from an activity.
Student Agreement: I agree to follow the expectations of the youth ministry and respect leaders and other students:
Parent/Guardian Signature: I certify that the information provided in this form is accurate and complete. I give permission for my child to participate in youth ministry activities for the program years listed above:
Should be Empty:

Student Registration Form

STUDENT INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE AND MEDICAL INFORMATION

STUDENT CONDUCT EXPECTATIONS