FCC Student Ministries Participation Form 2018-2019

Name of Participant *
Name of Participant
Date of Birth
Date of Birth
Address
Address
Students Cell Phone #
Students Cell Phone #
Name of Parent or Guardian
Name of Parent or Guardian
Same Address as Student? *
If not, please Provide Address
If not, please Provide Address
Parent or Guardian Work #
Parent or Guardian Work #
Parent or Guardian Home #
Parent or Guardian Home #
Parent or Guardian Cell # *
Parent or Guardian Cell #
Is the participant covered by insurance? *
If Parent information differs from Emergency Contact Information, please fill out section below
If Parent information differs from Emergency Contact Information, please fill out section below
Emergency Contact Information
Emergency Contact Phone #
Emergency Contact Phone #
Website Content Disclosure *
I, the parent of guardian of the participant, certify that he/she has my full approval to participate in FCC programs and attended events in the years 2018/2019. I accept the risk of physical injury associated with participation in these. Fork Christian Church Ministries Leaders assume responsibility of discipline at the event and, if necessary, may because of misconduct, require a participant to leave. In such instances, I will assume full responsibility for returning the participant home. Further, I do hold blameless Fork Christian Church and its employees and agents from any claim arising by reason of participating in FCC programs or associated events. Further, I do authorize the FCC employees or agents, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical treatment. It is understood that I will assume financial responsibility for any expense that may be incurred during said treatment. Signature of Parent or Legal Guardian