Family Ministries Registration Form | Palisades Presbyterian Church San Diego

Name (Required)

Email Address (Required)

Student Name (Required)

Student birth date (Required)

Student mailing address (Required)

Current Student Grade (Required)

Parent/Guardian Name (Required)

Parent/Guardian Phone Number (Required)

Parent/Guardian Email (Required)

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Email

Emergency Contact and phone number (Required)

Student Allergies

Student Health History - Major Conditions

Diabetes

Physical Disability

Nervous Disorder

Activity Restrictions

Chronic Asthma

Emotional Disability

Seizure Disorder

Epilepsy

Mental Health Issue

Other

Details of all checked items

Please explain each of the areas checked

Medications

Please list all medications currently being taken

Medical Insurance Company (Required)

Policy Number (Required)

Primary Doctor's Name (Required)

First and Last Name

Doctor's Phone Number (Required)

Release, Waiver & Indemnity Agreement (Required)

I understand and agree to release, waive, indemnify and hold harmless Palisades Presbyterian Church (the “Church”), and its directors, officers, employees, agents and representatives, with respect to any claims, costs, damages, losses, injuries, causes of action or liability based on or arising out of the participation of the above-named child (the “Child”) in the above-described activity (the “Activity”). This release, waiver and indemnity includes the Participant and the Participant’s parents, guardians, heirs, successors, assigns and estate. I also authorize the duly authorized agents and representatives of the Church to render or obtain such emergency medical care or treatment as may be necessary for the Participant should any injury, harm or accident occur to the Child while participating in the Activity. I/We understand that there are risks associated with any medical procedure and, knowing these risks, I/we agree to assume the risks. I further state and acknowledge that I/we are authorized to sign

Palisades Presbyterian requires permission for your student to be photographed or video recorded. These may appear on printed material or the church's website or social media. Do you agree to have your student photo video used as indicated above? (Required)

Parent/Guardian's Signature (Required)

Type name here to sign electronically. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury that I am authorized to enter into this Waiver and Release and that no other signature is required for this Waiver and Release to have legal effect.

Signed on behalf of: (Required)

Type the Child's Full Name

Please add me to the mailing list (Required)

Email is our main form of communication. By checking the box below you are opting in to receive regular information emails regarding our events, ministry and activities.

Please send me emails