JRC Student Registration 2024-25

STUDENT INFORMATION

Student Name

Birthdate

Gender

Male Female

Allergies, Medical or Special Needs (Please respond N/A if none)

FAMILY INFORMATION

Father's Name

Father's Cell/Phone

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:

Member Regular Attender Visitor

Home Church

DISMISSAL PREFERENCE

Child Release

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 2024 – August 2025. 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.

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.

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.

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.

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

JRC Student Registration 2024-25

Description

Please Fix the Following