EmailMe Form - Bethel Registration/Medical Form

Participant's Name *

First Last

This form is being submitted for the following activity and/or group(s):
(check all that apply) *

School grade or Preschool Class (as of Sept 2018) *

Gender *

Male

Female

Participant's Birth Date *

MM / DD / YYYY

Participant's Address *

Street Address City State / Province / Region Postal / Zip Code

Parent/Guardian Name *

First Last

Parent/Guardian Email *

Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Additional Parent/Guardian Name

First Last

Additional Parent/Guardian Email

Phone

### - ### - ####

Cell Phone

### - ### - ####

Participant 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.