JRC STUDENT REGISTRATION FORM 2021-2022
2021-2022 | Please fill out this form for each child that will be participating in programs at JRC this school year.
STUDENT INFORMATION
Student Name
*
Birthdate
*
Gender
*
Please select one option.
Male
Female
Grade Entering Fall of 2021
*
Please select one option.
Nursery
Age 3
Preschool/Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Allergies, Medical or Special Needs
FAMILY INFORMATION
Father's Name
Father's Cell
Mother's Name
Mother's Cell/Phone
*
Primary Address
*
Primary E-mail
*
This address will receive a confirmation email
Non-Guardian Emergency Contact Name
*
Non-Guardian Emergency Contact Phone
*
Are you a JRC:
*
Please select one option.
Member
Regular Attender
Visitor
Home Church
DISMISSAL PREFERENCE
Child Release
*
Please select one option.
Release to an approved adult listed below
Excuse child - no adult needed for pick up
Check this box if child is 6th-12th grade
Approved Adults for Pick up
LIABILITY & MEDICAL WAIVER
The undersigned does hereby give permission for our (my) child(ren) listed on this form to attend and participate in Jamestown Reformed Church children or youth ministry activities, events, and retreats during the period of June 2021 – August 2022. In consideration of Jamestown Reformed Church allowing Participant(s) to participate in children or youth ministry activities we (I) the undersigned, do hereby release, forever discharge and agree to hold harmless Jamestown Reformed Church, its directors, employees, volunteers and agents (collectively here in the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in child/youth ministry activities, including trips away from the church premises. Furthermore, we (I) [on behalf of our (my) minor Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Church to furnish any necessary transportation (within the limitations of church insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Church for any liability sustained by said Church as a result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto. We (I) authorize an adult, in whose care of the minor has been entrusted, to consent to an emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment at a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
*
Please select one option.
I accept
PHOTO RELEASE
We (I) give permission for photos or electronic images of our (my) child or youth to be used in the church publications, multimedia presentations, in future promotion, and on the Jamestown Reformed Church web site.
*
Please select one option.
I accept
TRANSPORTATION PERMISSION
The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by Jamestown Reformed Church. My child/youth and I understand that seat belts shall be worn at all times during transportation.
*
Please select one option.
I accept
EARLY RETURN HOME POLICY
Should it be necessary for our (my) child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportations costs and responsibility.
*
Please select one option.
I accept
Doctor's Name
*
Doctor's Phone
*
Preferred Hospital
*
Electronic Signature of Parent or Legal Guardian
*
Date Signed
*
Electronic Signature of Middle or High School Student
Date Signed
Submit
Description
2021-2022
Please fill out this form for each child that will be participating in programs at JRC this school year.
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