Hearts on Fire Registration
Student Name
First Name
Last Name
Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Parent/Guardian Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Permission to send text messages to the above phone numbers (yes or no)
As the parent/legal guardian of the minor mentioned above, I give he/she permission to participate in all activities associated with the Hearts on Fire Conference with Thorn Grove Baptist Church. I acknowledge that TGBC will not be held responsible for any damages/liabilities to any property. I give my consent to TGBC leaders and volunteers to make any medical decisions deemed necessary while my child is under the supervision of TGBC and its leaders and volunteers. TGBC will not be held responsible for any expenses in the event of an emergency where medical care is deemed necessary. My child will adhere to all rules given by TGBC and its leaders. By entering your name and today's date, you are agreeing to the above waiver and give permission to your child to participate with Thorn Grove Baptist Church.
Medical Insurance Company
Policy Number
Group Number
Name of family member policy is under
First Name
Last Name
Family Physician
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Emergency Contact (different from above)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Emergency Contact (different from above)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
List any physical limitations/needs we need to know about or may hinder participation in activities (allergies, asthma, migraine headaches, stings, bites, etc.)
List any special instructions should medical treatment required (rare blood types, medication allergies, high blood pressure, etc.)
List any medications and instructions that will need to be given (ALL medication will be kept by an adult and distributed at the appropriate time)
May we have permission to photograph your child? (yes or no)
May we have permission to use your child's photograph for the purpose of promotion (church website, Facebook, etc.)? (yes or no)
By entering your name and date you agree that the above medical information is correct and release Thorn Grove Baptist Church from any and all liability
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