Student's Name *
Student's Name
Date of Birth *
Date of Birth
The grade your student will be going into Fall of 2017-18 school year
Sex *
Address *
Address
Parent's Name *
Parent's Name
Skill Session Choices:
Please note: Classes are divided by age. We will make every effort to place children in their first or second class for each session; however, some class sizes are limited! Get your registration submitted as soon as possible! Please choose your 1st, 2nd, and 3rd choice for both your morning session and afternoon session. Please choose NA for the selections that don't pertain to your age range.
4th-6th Grades ONLY
Your first choice
Your second choice
Your third choice
Your first choice.
Your second choice
Your third choice
Medical Release Form
Does your child have any physical disability? *
If yes, please describe below
Is your child getting or thinking about getting medical treatment or taking any medications, pills, shots, or other drugs? *
If yes please describe below.
Does your child have any physical or mental disability that would limit participation? *
If yes, please describe below
Has your child ever had chest pain, heart trouble, heart murmurs, or high blood pressure? *
If yes, please describe below
Has your child ever had diabetes, urinary problems, arthritis, ulcers, asthma, allergies or allergic reactions to any medications? *
If yes please describe belwo
Does your child have any allergies to food? *
if yes, please describe the types of food and what kind or reactions they have below.
Will any problems result from vigorous physical activity? *
If yes please describe the issues below.
Is your child unusually sensitive to heat? *
Please describe below
Has your child ever been completely or partially overcome by heat? *
If so, please describe situation below
Emergency Contact Information
First Emergency Contact Name: *
First Emergency Contact Name:
First Emergency Contact Address *
First Emergency Contact Address
First Emergency Contact Phone # *
First Emergency Contact Phone #
Second Emergency Contact Name *
Second Emergency Contact Name
Second Emergency Contact Address *
Second Emergency Contact Address
Second Emergency Contact Phone #: *
Second Emergency Contact Phone #:
(numbers only, if you have letters in your policy # please put that in your insurance company information notes field above.)
I, the undersigned (and we the parents or legal guardians and/or custodians pf the undersigned of a minor or under legal disability) in consideration of the services and sponsorship of Life Church all other valuable consideration and permission of Life Church for me to go to this even under its auspices, HEREBY RELEASE AND AGREE TO HOLD HARMLESS LIFE CHURCH and all of its officers, employees, agents and servants from liability whatsoever that might involve me or any other person, corporation, agency or governmental unit whatsoever, as a result, whether immediate or proximate or not, of my participation in this event sponsored by Life Church, and I specifically agree to provide agree to provide any and all insurance protection that may be necessary, helpful or desirable for my participation and that I will not relay upon Life Church for such protection. I furthermore give my permission for any and all pictures, audio, videos, or personal testimonies to be used in part or in whole in any and all future publications printed or recorded (audio or video) without prior notification or royalties.