Please fill this form out in its entirety. Do not leave any blank spaces.

Your Name

Address

City

State

Zip

Home Phone

Cell Phone

Email

Grade

Birthdate

Gender
MaleFemale

T-Shirt Size
SmallMediumLargeXLXXLXXXL

PARENT / GUARDIAN INFORMATION

Name of MOM:

Name of DAD:

LEGAL GUARDIAN

Address

City

State

Zip

Home Phone

Mom Work Phone

Mom Cell Phone

Email Address

Dad Work Phone

Dad Cell Phone

Email Address

Another Emergency Name and Number other than parents.

NAME

Home Phone

Cell Phone

INSURANCE COMPANY: PROVIDE A PHOTO COPY OF BOTH SIDES OF YOUR INSURANCE CARD.

No InsuranceSelf Insured

MEDICAL HISTORY

(Please check all that apply and provide appropriate information)

AsthmaUlcersSinusitisKidney TroubleBronchitisHeart TroubleDiabetesDizzinessOther (List below)

Previous operation or illness:

Date of last Tetanus shot:

Any current special medications:

Name and Number of Physician:

Name Number

ALLERGIES

Food:

Penicillin/Other Drugs:

Insect Stings or Bites:

Poison Sumac, Ivy, Oak:

Parental Consent

My permission is granted for Riverview Baptist Church, staff, sponsors, or chaperones in charge to obtain necessary medical attention in case of sickness, injury, or accident to my child, and that any expenses incurred are my responsibility. Riverview Baptist Church will not be held liable for the loss of money or other personal items that may be lost or missing. Any damages or losses caused by my child, individually or with a group shall become my responsibility.

Use of any tobacco products, intoxicating beverages and/or drugs shall be prohibited. Other rules that are established to ensure proper health, safety, and enjoyment for all concerned shall be enforced. Failure to cooperate within these standards will result in my child being sent home early, and I; him/her; and he/she understands both the expectations and the consequences for failure to meet those expectations.
I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and forever discharge all staff, members, in an organized activity of Riverview Baptist Church.

I agree.

Signed (Parent/Guardian)

dated this day of , 2019 Tulsa County, Oklahoma