Student Ministries | Palos Heights Christian Reformed Church

Student Ministries Registration Form

Parent/Guardian Name*

Cell Phone Number*( ) -

Email*

Address*

Additional Parent/Guardian Name

Cell Phone Number( ) -

Student's Name*

Cell Phone Number (If Applicable)( ) -

Grade*

Birthday*

List any allergies or medical conditions

Cadets Only: Optional Event - Kick off Campout: My cadet will be attending the kick off campout Aug 18-20th. This event is optional, but there is a $30 fee. Make checks payable to Palos Heights CRC, memo line can be Cadets

Yes

Separate Illiana Cadet Council permission form will need to be filled out later

Cadets Only: If yes for cadet campout, will an adult male relative (father, grandfather, father figure) will be attending as well. Please respond with Yes/No and name.

GEMS ONLY: Check Yes or No if you are joining us for the retreat on September 11-13.

Yes

Undecided

Additional Student's Name

Cell Phone Number (If Applicable)( ) -

Grade

Birthday

List any allergies or medical conditions

Yes

Separate Illiana Cadet Council permission form will need to be filled out later

Cadets Only: If yes for cadet campout, will an adult male relative (father, grandfather, father figure) will be attending as well. Please respond with Yes/No and name.

GEMS ONLY: Check Yes or No if you are joining us for the retreat on September 12-14

Yes

Undecided

Additional Student's Name

Cell Phone Number (If Applicable)( ) -

Grade

Birthday

List any allergies or medical conditions

Yes

Separate Illiana Cadet Council permission form will need to be filled out later

Cadets Only: If yes for cadet campout, will an adult male relative (father, grandfather, father figure) will be attending as well. Please respond with Yes/No and name.

GEMS ONLY: Check Yes or No if you are joining us for the retreat on September 11-13

Yes

Undecided

Emergency Contact Name (if different than parents cell phone numbers)

Emergency Contact Number (if different than parents cell phone numbers)( ) -

Church Name*

School*

If you need to register more students, please begin a new form.

I will not send my child to a Palos Heights CRC ministry if they have any symptoms of sickness such as: fever, cough, sore throat, etc.

I give my permission for my child's photo/video to be taken and used for Palos Heights CRC and supporting ministries media and promotions. I hereby release Palos Heights CRC from all claims and liabilities arising out of the use of these photos and videos .

I hereby give permission for my child to participate in all Youth Ministries special events and to be transported by designated leaders when activities take place off-site from Palos Heights CRC. I release and hold harmless Palos Heights CRC, its leaders, volunteers, and sponsors from any and all claims or liabilities arising from incidents that may occur during these events or in the course of travel to, from, or during activities. Furthermore, in the event of illness or injury to my child during one of these events, I authorize those in charge to take whatever steps are necessary to provide appropriate medical care. If I cannot be reached by phone, I consent to the administration of treatment as advised by a duly licensed physician and/or surgeon. I give the leaders at PHCRC consent to obtain medical treatment for my child if necessary during a PHCRC ministry.

By Checking the boxes, I am giving permission to Palos Heights CRC and agreeing to follow the guidelines and policies. I understand this consent will remain in effect until a written request to revoke consent is received by Palos Heights CRC *

Parent/Guardian name

Please leave this field blank.