Heritage Baptist Church Registration Form

Heritage Baptist Church Registration / Permission Forms
Activity or Event: ____________________________________ Date(s): _____________________
A new and separate form is required for each activity or program where adults or children
are transported to / from activities or events away from the Heritage Baptist Church campus.
ADULT PARTICIPANT comp lete sections A - C - D - F
CHILDRENORYOUTHPARTICIPANTcompletesectionsB‐C‐D‐EF
A. GENERAL INFORMATION (ADULT PARTICIPANT)
Participant: _________________________________________________ Male _____ Female _____
Street Address: _____________________________ City: ______________________ Zip: _________
Home Phone: (____)_____________Work: (____)________________Cell:(____)_________________
Email: __________________________________________________________________________________
B. GENERAL INFORMATION (CHILD OR YOUTH PARTICIPANT)
Participant: ___________________________________________________Male _____ Female _____
School: _________________________________________________________ Age: _____Grade: _____
Home Address: ______________________________ City: ______________________ Zip: _________
Home Phone: (____)____________Cell: (____)_________ Email: _____________________________
Is there anyone your child should “not” be released to? _____________________________
PARENT / GUARDIAN INFORMATION
Name of Parent / Guardian: ___________________________________________________________
Home Address: ______________________________City: ______________________ Zip: _________
Home Phone: (____)________________ Work: (____)___________Cell: (____)___________
Email: _________________________________________________________
C. EMERGENCY CONTACTS
Name Contact: _________________________ Relationship: _______________________________
Home Phone: (____)_____________Work: (____)_______________ Cell: (____)_________________
Name Contact: __________________________ Relationship: _______________________________
Home Phone: (____)_______________Work: (____)_____________Cell: (____)_________________
D. HEALTH / INSURANCE INFORMATION
Health Insurance Co. ___________________ ID/Policy # ______________Group # ___________
Family Doctor: _____________________________________________ Phone# ___________________
MedicalProblems/Allergies:____________________________________________________________
Special DietaryNeeds:_________________________________________________________________
Current Medications:___________________________________________________________________
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Heritage Baptist Church Registration Form PDF

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