Child's Name:

MaleFemale   Birthdate:

Grade Just Completed:

Street Address:

City:   State:   Zip Code:

Shirt Size (Children's Sizes): SmallMediumLarge

Parent(s) Name(s):

Parent(s) Phone Number(s):

Parent(s) Email(s):

In case of emergency, contact:

Allergies or other medical conditions:

Health Insurance Carrier:

Group/Policy Number:

Person responsible for insurance coverage:

Doctor’s Name:

Doctor’s Phone Number:

Hospital Preference:

The following people are authorized to pick up this child:

Parent or Guardian Authorization

has my permission to participate in NCC youth activities. I understand that all activities will be closely supervised, and that medical and/or hospital care will be given if serious illness or injury occurs. I understand that I will be notified in case of serious injury or illness, and if I cannot be contacted, I give permission for emergency treatment as recommended by attending physician or dentist. I further release all volunteer/paid staff and NCC itself from responsibility and liability for any accidents or illness occurring during any and all activities. I understand that the church insurance coverage picks up where my insurance leaves off, up to the limits of the church policy.

By checking this box, I hereby certify that all the information above is correct and give permission for the use of photographs including my child to be used in publicity for the youth ministry of Noelridge Christian Church (NCC).

Date: