EmailMeForm
Bethel Registration/Medical Form
Please complete the form below for each child participating in a Bethel Church group, Sunday School or function within this school-year cycle.
Remember that you need only complete one form per child even if they will participate in more than one group. The information will be stored for all groups you check below. Thank you!
Participant's Name
*
First
Last
This form is being submitted for the following activity and/or group(s):
(check all that apply)
*
Sunday School
King's Kids (K-2nd grade)
"J" Crew (3rd-6th grade)
Youth Music Ministry - YM2 (7th-12th grade)
FUEL Youth
School grade or Preschool Class (as of Sept 2023)
*
Please select
2 yr preschool
3 yr preschool
4 yr preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Gender
*
Male
Female
Participant's Birth Date
*
MM
/
DD
/
YYYY
Participant's Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Participant's Home Phone
*
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-
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-
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Participant's Cell Phone
(YM2 only)
###
-
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-
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Cell Phone Permission
Please indicate if you allow your child to receive texts from a Bethel employee related to YM2 or Youth Group (ie. reminders, Bible verses and discussion topics)
*
Yes, I give permission.
No, I do not give permission.
If your child does not have a cell phone or if you choose to not provide us with the number, simply click NO, here.
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name
*
First
Last
Parent/Guardian Email
*
Parent/Guardian Cell Phone
*
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-
###
-
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Additional Parent/Guardian Name
First
Last
Additional Parent/Guardian Email
Home Phone
###
-
###
-
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Cell Phone
###
-
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MEDICAL INFORMATION
The following information is required for use in case of medical emergency only.
List any allergies or drug sensitivities:
*
Name of Health Insurance Carrier:
*
Insurance Group #:
*
List any medical conditions or physical/developmental disabilities that we should be aware of:
Additional Information
Publicity Permission:
Please indicate if you would allow pictures of this participant to be used for Bethel publicity purposes on our website, local newspapers, etc.
*
Yes, I allow pictures to be used for publicity
No, I DO NOT allow pictures to be used for publicity
Name of person completing this form:
*
First
Last
Please indicate if you are interested in volunteering in any of the following areas:
Sunday School Teacher
Choir Parent
Youth Leader/Volunteer
Have you taken the Safe Sanctuary On-line Training within the past two years?
Yes
No
Signature of person completing this form:
*
Clear
Please sign using either your mouse or your finger/stylus on a touch screen. By signing you affirm that you have read and agree to follow the covid safety protocol above. Thank you for your understanding and cooperation.
