Faith Church //

Click here to download the registration form.

Name
Address
City, State, Zip
Phone	555-555-5555
E-Mail
Birthday	MM/DD/YYYY
Grade	(grade coming out of)
Parent's Name
Em. Contact
Em. Phone	555-555-5555
Medications
Payment

I, (Parent/Guardian's Name) hereby give permission for any and all medical attention or treatment to be administered to my child in the event of an accident, injury, sickness, etc. I hereby release Faith Church, and its employees and representatvies of any and all liability with respect to bills incurred or decisions made by them as a result of the medical treatment and/or transportation necessary for my child. This release is effective for a period of one year from June 2011.

Signature	Print Name
Insurance Company
Policy Holder
Policy #

Payment must be received on next screen to be fully registered.