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.
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
"J" Crew
Youth Music Ministry (YM2)
FUEL Youth
School grade or Preschool Class (as of Sept 2018)
*
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
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.
Physician:
*
Physician Phone #
*
###
-
###
-
####
Dentist:
Dentist Phone #
###
-
###
-
####
Eye Doctor:
Eye Doctor Phone #
###
-
###
-
####
Other:
Other Phone #
###
-
###
-
####
List any allergies or drug sensitivities:
*
Name of Health Insurance Carrier:
*
Insurance Group #:
*
Has the participant been treated by a physician, been disabled or hospitalized during the past year?
(explain if yes)
Date of last physical
MM
/
DD
/
YYYY
Date of last tetnus shot
MM
/
DD
/
YYYY
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
Date Completed:
*
MM
/
DD
/
YYYY
Signature of person completing this form:
*
Clear
Please sign using either your mouse or your finger/stylus on a touch screen.
