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
- Grade
- School
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- Would you like to register another person?
- Name
  
  First NameLast Name
- E-mail
- Birth Date:
  
  MonthDayYear
- Grade
- School
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- Would you like to register another person?
- Name
  
  First NameLast Name
- E-mail
- Birth Date:
  
  MonthDayYear
- Grade
- School
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- Would you like to register another person?
- Name
  
  First NameLast Name
- E-mail
- Birth Date:
  
  MonthDayYear
- Grade
- School
- List any medical allergies, medication being taken, medical problems, or other pertinent information
- Would you like to register another person?
- Name
  
  First NameLast Name
- E-mail
- Birth Date:
  
  MonthDayYear
- Grade
- 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
- For my child to ride in any vehicle designated by the adult in whose car the minor has been entrusted while attending and participating in activities sponsored by North Park Baptist Church of Grand Rapids, Michigan. All drivers have agreed to staff expectations and/or have been screened through a background check.
- NORTH PARK BAPTIST CHURCH - Media Release Form
- For my child/children to be photographed and/or videotaped during any and all scheduled church activities. I furthermore agree that any photographs or video may be published either on the church’s website or printed for use in publication and/or advertisement of Student Ministries of North Park. I understand that my child’s name will not be used, just their image.
- 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