Houseboats Registration
Home
2019 Houseboats Registration
About
Details
Payment
Student Agreement
Contact Us
Winter Camp 2018
Home
2019 Houseboats Registration
About
Details
Payment
Student Agreement
Contact Us
Winter Camp 2018
Houseboats Registration
REGISTRATION Houseboats 2019
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
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
MM
DD
YYYY
T-Shirt Size
*
—
Sm
Med
Lg
XL
Grade Student is Entering
*
—
9th
10th
11th
12th
College Freshmen
Student 1 Cell
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
*
—
glasses
contacts
none
For your student’s safety and our knowledge, is your student a
*
—
good swimmer
fair swimmer
non-swimmer
Should your student be restricted from any activities for any reason?
Student 2 (optional)
Student 2
Student 2
First Name
Last Name
Date of Birth
Date of Birth
MM
DD
YYYY
T-Shirt Size
—
Sm
Med
Lg
XL
Grade Student is Entering
—
9th
10th
11th
12th
College Freshmen
Student 2 Cell
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
—
glasses
contacts
none
For your student’s safety and our knowledge, is your student a
—
good swimmer
fair swimmer
non-swimmer
Should your student be restricted from any activities for any reason?
Student 3 (optional)
Student 3
Student 3
First Name
Last Name
Date of Birth
Date of Birth
MM
DD
YYYY
T-Shirt Size
—
Sm
Med
Lg
XL
Grade Student is Entering
—
9th
10th
11th
12th
College Freshmen
Student 3 Cell
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
—
glasses
contacts
none
For your student’s safety and our knowledge, is your student a
—
good swimmer
fair swimmer
non-swimmer
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
Thank you!