Student #1 *

First Name

Last Name

Student # 2

First Name

Last Name

Student #3

First Name

Last Name

Are there any allergies, disabilities, or health concerns we should be aware of? *

Yes

No

I give my permission to Calvary Chapel Center City to drive my child(ren) to and from Calvary Chapel Center City’s Youth Events. *

Select one:

Yes

No

MEDICAL TREATMENT: In the event on an emergency, I hereby consent and authorize permission for emergency medical treatment for my child(ren) (listed below). I agree to release Calvary Chapel Center City, its leaders, employees, or volunteer staff, and all youth event chaperones or drivers from any liability for any damages, losses, or injuries incurred. *

Select one:

Yes

No

Parent's Name *

First Name

Last Name

Parent's Phone # *

(###)

###

####

Emergency Contact #1 *

In the event of an emergency, the Parent listed above would be the first person contacted. If we are unable to get in contact with you, please list a second emergency contact!

First Name

Last Name

Emergency Contact #1: Phone Number *

(###)

###

####

Emergency Contact #2

First Name

Last Name

Emergency Contact #2: Phone Number

(###)

###

####