Houseboats Registration — Houseboats Registration

Guardian (required)

Guardian's Name *

Guardian's Name

First Name

Last Name

Guardian's Phone *

Guardian's Phone

(###)

###

####

Guardian's Email Address *

Guardian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If guardians cannot be contacted, please contact *

If guardians cannot be contacted, please contact

First Name

Last Name

Their phone number *

Their phone number

(###)

###

####

Student 1 (required)

Student 1 *

Student 1

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

T-Shirt Size *

Grade Student is Entering *

Student 1 Cell

(###)

###

####

Student 1 Email

Student 1 Medical Conditions/Allergies (Mark N/A if none) *

Current Prescriptions (Mark N/A if none) *

Check all medications that SHOULD NOT be administered to your child

Aspirin

Ibuprofen

Motrin

Antihistamine(Benadryl, etc.)

Pepto Bismol

Other

Other Medication

Does your student suffer from, ever experienced, and/or is being treated currently for any of the following *

None

asthma

epilepsy / seizure disorder

heart trouble

diabetes

frequently upset stomach

physical handicap

Student Wears *

For your student’s safety and our knowledge, is your student a *

Should your student be restricted from any activities for any reason?

Student 2 (optional)

Student 2

First Name

Last Name

Date of Birth

YYYY

T-Shirt Size

Grade Student is Entering

Student 2 Cell

(###)

###

####

Student 2 Email

Student 2 Medical Conditions/Allergies (Mark N/A if none)

Current Prescriptions (Mark N/A if none)

Check all medications that SHOULD NOT be administered to your child

Aspirin

Ibuprofen

Motrin

Antihistamine(Benadryl, etc.)

Pepto Bismol

Other

Other Medication

Does your student suffer from, ever experienced, and/or is being treated currently for any of the following

asthma

epilepsy / seizure disorder

heart trouble

diabetes

frequently upset stomach

physical handicap

Student Wears

For your student’s safety and our knowledge, is your student a

Should your student be restricted from any activities for any reason?

Student 3 (optional)

Student 3

First Name

Last Name

Date of Birth

YYYY

T-Shirt Size

Grade Student is Entering

Student 3 Cell

(###)

###

####

Student 3 Email

Student 3 Medical Conditions/Allergies (Mark N/A if none)

Current Prescriptions (Mark N/A if none)

Check all medications that SHOULD NOT be administered to your child

Aspirin

Ibuprofen

Motrin

Antihistamine(Benadryl, etc.)

Pepto Bismol

Other

other medication

Does your student suffer from, ever experienced, and/or is being treated currently for any of the following

asthma

epilepsy / seizure disorder

heart trouble

diabetes

frequently upset stomach

physical handicap

Student Wears

For your student’s safety and our knowledge, is your student a

Should your student be restricted from any activities for any reason?

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.

I agree to these terms

First Name

Last Name

REGISTRATION Houseboats 2019