Rebelbase: High School Home Groups (Small Groups)
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Student's First Name
Student's Last Name
Mother's Full Name
Mother's Cell Number
Mother's Work Number
Father's Full Name
Father's Cell Number
Father's Work Number
Student's Primary Address
Parent Email Address
Student Email Address
Please Select Answer
Student's Date of Birth
Any Food Allergies?
Is there any medical information we should know?
EMERGENCY CONTACT INFORMATION
Emergency Contact (other than a parent)
Relationship to Student
Emergency Contact's Phone Number(s)
Is there anything else that we should know about your child to help them have a successful event? If not, than n/a
Photo Release - I give permission for photos and videos taken at this event can be used for promotional purposes on church website, social media platforms and/or newsletter
I hereby grant permission for my child to participate in all of the activities of The Woodlands United Methodist Church. I hereby grant permission for my child to leave the church premises under supervision of an authorized adult for church related activities. I hereby waive any claim against The Woodlands United Methodist Church, The Woodlands, Texas. I hereby grant permission for the Minister, Staff Person, Acting Director, or authorized counselor to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to the following: 1. Attempt to contact parents/guardians through the numbers listed on this form. 2. Attempt to contact the child’s physician 3. If we cannot contact your child’s physician, we will do any of the following: -Call another physician or paramedics -Call an ambulance -Have the child taken to an emergency hospital in the company of a staff member 4. Any expenses incurred under item 3 will be borne by the family. 5. The church will not be responsible for anything that may happen as a result of false information given at the time of registration.
By typing my name below I am electronically signing this document affirming that I am least 18 years old; or this form has been filled out and/or approved by a parent or legal guardian.
E-Signature (Full Name)
9/17/2017 3:00 PM -
4/29/2018 5:00 PM
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