Breakaway Registration Form 2017-18

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Registration Form

Sept. 1, 2019 - Aug. 31, 2020
NORTH PARK BAPTIST CHURCH–Medical/Liability Release Form

3365 Coit Ave NE, Grand Rapids, MI 49525 616-364-9532 office@npbc.us
- Personal Information:
- Name*
  
  First NameLast Name
- E-mail
- Birth Date:*
  
  MonthDayYear
- 23456789101112
- School*
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- YesNo
- Name*
  
  First NameLast Name
- E-mail
- Birth Date:*
  
  MonthDayYear
- 791181012
- School*
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- YesNo
- Name*
  
  First NameLast Name
- E-mail
- Birth Date:*
  
  MonthDayYear
- 791181012
- School*
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- YesNo
- Name*
  
  First NameLast Name
- E-mail
- Birth Date:*
  
  MonthDayYear
- 791181012
- School*
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- YesNo
- Name*
  
  First NameLast Name
- E-mail
- Birth Date:*
  
  MonthDayYear
- 791181012
- School*
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- Primary Parent/Guardian:
- Name*
  
  First NameLast Name
- E-mail*
- Phone Number:*
  
  Area CodePhone Number
- Address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Secondary Parent/Guardian:
- Name
  
  First NameLast Name
- E-mail
- Phone Number:
  
  Area CodePhone Number
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Emergency Contact Person:
- Name*
  
  First NameLast Name
- Phone Number:*
  
  Area CodePhone Number
- Relation to the Student*
- Insurance Information
- Insurance Company*
- Policy #*
- Group #*
- Hospital Preference*
- Doctor's Name*
  
  First NameLast Name
- Doctor's Phone Number*
  
  Area CodePhone Number
- I understand that if medical intervention is needed for this child during this activity, every attempt will be made to consult the contact persons listed on this form. If, however, those persons cannot be reached, I give my permission to the activity leaders to secure the services of a licensed physician or surgeon to provide medical treatment, including anesthesia, that is deemed necessary for the well-being of this child.
- I understand all reasonable safety precautions will be taken at all times by North Park Baptist Church and its agents during events, trips and activities. I also understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to release, forever discharge and hold harmless North Park Baptist Church, its leaders, employees, and volunteer staff from any and all liability and claims for damages, losses, sickness of injury incurred by this child.
- Please include a copy of your family's insurance card below
- Upload Front of Card
  
  Cancelof
- Upload Back of Card
  
  Cancelof
- NORTH PARK BAPTIST CHURCH - Transportation Release Form
- Yes, I do give my permissionNo, I do not give my permission
- NORTH PARK BAPTIST CHURCH - Media Release Form
- Yes, I do give my permissionNo, I do not give my permission
- Please Sign the Form Below
- Signature*
- Name of the Person Filing Registration*
  
  First NameLast Name
- Today's Date*
  
  MonthDayYear
- Thanks for registering with Breakaway for this year!
- Should be Empty:

Registration Form

Personal Information:

Primary Parent/Guardian:

Secondary Parent/Guardian:

Emergency Contact Person:

Insurance Information

Please include a copy of your family's insurance card below

NORTH PARK BAPTIST CHURCH - Transportation Release Form

NORTH PARK BAPTIST CHURCH - Media Release Form

Please Sign the Form Below