REGISTRATION

Guardian (required)
Guardian's Name *
Guardian's Name
Guardian's Phone *
Guardian's Phone
Guardian's Address
Guardian's Address
If guardians cannot be contacted, please contact *
If guardians cannot be contacted, please contact
Their phone number *
Their phone number
Student 1 (required)
Student 1 *
Student 1
Date of Birth *
Date of Birth
Student 1 Cell
Student 1 Cell
Check all medications that SHOULD NOT be administered to your child
Does your student suffer from, ever experienced, and/or is being treated currently for any of the following *
Student 2 (optional)
Student 2
Student 2
Date of Birth
Date of Birth
Student 2 Cell
Student 2 Cell
Check all medications that SHOULD NOT be administered to your child
Does your student suffer from, ever experienced, and/or is being treated currently for any of the following
Student 3 (optional)
Student 3
Student 3
Date of Birth
Date of Birth
Student 3 Cell
Student 3 Cell
Check all medications that SHOULD NOT be administered to your child
Does your student suffer from, ever experienced, and/or is being treated currently for any of the following
Authorization *
We, the undersigned parent(s) or guardian(s) of the above mentioned minor(s), do hereby grant permission for my son/daughter to travel or stay at over night event with representatives of Glendale Presbyterian Church.

If deemed necessary for my students’ health, I (we) authorize representatives of Glendale Presbyterian Church to consent to any examination, x-ray, anesthetic, medical, or surgical diagnosis rendered under the general or special supervision of any physician or surgeon, licensed staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. In any case all such expenses shall be paid by the parent except where covered by the Accident Insurance Policy.
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