2026-27: Child/Student Registration Form

Permissions
These additional individuals are authorized to pick up this child(ren) from SHBC ministries or events. (In addition to parents and the Secondary Emergency Contact)
Name*
Relationship *
Name*
Relationship *
YesNo
Date

MonthDayYear
Date
Preferred Physician*
Physician Phone Number*
Format: 000-000-0000.
OR in the event the appropriate specified practitioner is not available, by another licenced physician or dentists:

2. The transfer of minor to preferred hospital or any hospital reasonably accessible.
Preferred Hospital*
3. This authorization does not cover major surgery unless the medical opinions of two other licensed physicans or dentists concurring in the necessity for such surgery are obtained in writing prior to the performance of such surgery.
I AGREE*
Initial Here
Date

MonthDayYear
Date
Please Print *

First NameLast Name
Signature*
Should be Empty: