Student Ministries | Palos Heights Christian Reformed Church

Student Ministries Registration Form

Parent/Guardian Name*

Cell Phone Number*( ) -

Email*

Address*

Additional Parent/Guardian Name

Cell Phone Number( ) -

Student's Name*

Grade*

Birthday*

List any allergies or medical conditions

GEMS ONLY: Check Yes or No if you are joining us for the retreat on September 13-15

Yes

Undecided

Cell Phone Number (If Applicable)( ) -

Additional Student's Name

Grade

Birthday

List any allergies or medical conditions

GEMS ONLY: Check Yes or No if you are joining us for the retreat on September 13-15

Yes

Undecided

Cell Phone Number (If Applicable)( ) -

Additional Student's Name

Grade

Birthday

List any allergies or medical conditions

GEMS ONLY: Check Yes or No if you are joining us for the retreat on September 13-15

Yes

Undecided

Cell Phone Number (If Applicable)( ) -

Emergency Contact Number (if different than parents cell phone numbers)( ) -

Church Name*

School*

If you need to register more students, please begin a new form.

I will not send my child to a Palos Heights CRC ministry if they have any symptoms of sickness such as: fever, cough, sore throat, etc.

I give permission for my child to leave church property with a Palos Heights CRC leader for special events. This would include transportation by leaders. I hereby release Palos Heights CRC from all claims and liabilities arising out of providing transportation.

I give my permission for my child's photo/video to be taken and used for Palos Heights CRC media and promotions. I hereby release Palos Heights CRC from all claims and liabilities arising out of the use of these photos and videos .

I give the leaders at PHCRC consent to obtain medical treatment for my child if necessary during a PHCRC ministry.

By Checking the boxes, I am giving permission to Palos Heights CRC and agreeing to follow the guidelines and policies. I understand this consent will remain in effect until a written request to revoke consent is received by Palos Heights CRC *

Parent/Guardian name

Please leave this field blank.