Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Emergency Contact (Relation to Student)

Parent

Relative

Other

Family Physician

First Name

Last Name

Family Physician Phone

(###)

###

####

Insurance Phone

(###)

###

####

Immunization History

DTP

Hepatits B

HIB

MMR

Oral Polio

Tetanus

I authorize adult leaders of Bethel Church to consent to medical care for my child in the event the parent/guardian can't be reached and/or administer care for minor discomfort. *

Yes

No

I authorize adult leaders of Bethel Church to transport my child off site for planned and communicated trips. (A separate release form may be needed for any specific activities that are planned, which may include activities like missions trips, retreats, etc.) *

Yes

No

I authorize Bethel church to use photographs of my child on church publications (print/online) for the purpose of promotion. *

Yes

No