Form
Student Information
Name
First Name
Last Name
Grade
Date of Birth
-
Month
-
Day
Year
Date
Parent Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact (If different)
Emergency Phone Number(If different)
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Allergies:
Medications:
Other Medical Notes or Concerns:
Overnight & Pickup Information
Will your student be staying overnight?
Yes
No
Who is authorized to pick up your student?
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Permission & Medical Authorization
I give permission for my child to attend the Arise Youth Lock-In and participate in all scheduled activities.
*
Yes
In the event of a medical emergency, I authorize Arise Youth leaders to obtain medical treatment for my child if I cannot be reached.
*
Yes
Liability Acknowledgment
I understand that participation in activities involves some level of risk. I agree not to hold Arise Church, its staff, or volunteers liable for injuries that may occur during the participation of planned activities.
*
Yes
Parent/Guardian Signature
*
Date:
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: