Event Registration

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Student Central Registration 18.19 on Wednesday, September 5, 2018 @ 6:30 PM

FREE
Would your student consider volunteering in one of the following areas?
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Would you consider volunteering at Student Central in one of the following ways?
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*Student's Gender:
*Student's Grade:
*Student's School:
*Birth Date:
Any allergies, special food diet or other information (behavior challenges, phobias, etc.) we should know about your student?:
*If none, please type "none":
*Do you have health insurance?:
Was the student in a small group last year? (Won't apply to 6th Graders.):
*Small Group:
If yes, who was the student's small group leader last year?:
Please list 1 to 2 students whom the student would like to be in the same small group with:
*Please use full names. Students must be in the same grade & gender. If none, please type "none.":
Would your student want to raise funds to help offset your costs for future church trips and events? :
*Parent(s)/Guardian(s) Name:
*Parent Cell Phone Number:
Parents' Email Address:
Emergency Contact in case parent is unavailable:
Emergency Contact Phone Number:
I/We understand that there are inherent risks involved in any physical activity, as well as any other church activity or trip, and I/We hereby release Central Church, its staff and volunteer workers from any and all liability due to any injury, loss, or damage to person or property that may occur during the course of my/our involvement with any events and or all activities held by Central Student Ministries or Student Central of Central Church of Sioux Falls during the year of September 2018 - August 2019. As parent or legal guardian, I give permission for my child to participate in the following activities organized by Central Church, including but not limited to: • Weekly meetings including any outside transportation to and from weekly meeting MS & HS events.• Fun nights (youth group nights) involving transportation in Sioux Falls and surrounding communities• HS & MS small groups, activities that may involve transportation to houses in Sioux Falls and surrounding communities • Other Central sponsored youth activities and events. I understand that Central Church does not carry medical and hospitalization coverage for my child. I understand that my personal medical and hospitalization insurance policies will provide primary coverage. I further understand that in the event my child requires medical or dental treatment while engaged in the activity, reasonable efforts will be made to contact me. However, if I cannot be reached I hereby give consent and permission to the Youth Pastor or any adult sponsor acting on behalf of the ministry with respect to the activity, as agent for me, to administer or dispense: over the counter medications for the relief of minor aches, abrasions, cuts, or irritations and consent to any x-ray, examination, injections, anesthesia, medical, dental, or surgical diagnosis and treatment and hospital care and treatment advised and supervised by a licensed physician, surgeon, or dental (as appropriate) licensed to lawfully practice in the State where the services are rendered; either as an outpatient or by any hospital. To the best of my knowledge I have listed, above, all of my child’s known allergies, medications and prescriptions to be taken, medical conditions and other pertinent information. I give permission for Central to use any photos or digital images taken of my student :
I/We as parent(s)/guardian(s) hereby certify that I/We have read and clearly understand these terms and certify that this form is being executed voluntarily:
*Type Name as electronic Signature: