2024-25 Student Registration and Medical Release (Effective 8/1/24-7/31/2025)

Student Information

Student First & Last Name

Student Email Address (If None, Leave Blank)

Student Cell Phone Number (If None, Leave Blank)

Student Date of Birth

Student Grade (2024-25 School Year)

Student Gender

Male Female

Student Allergies/Special Needs

Student Medication

Do you have Medical Insurance

Yes, I will attach it below. No

Student Insurance Card

Upload (8MB)

Anything special we should know about your student?

Parent(s) Information

Parent's Name(s)

Full Address (Including City, State & Zip Code)

Mother's Cell Phone Number

Mother's Email Address

This address will receive a confirmation email

Father's Cell Phone Number

Father's Email Address

I give permission for my above named student to participate in Brookville Road Community Church student activities from August 1, 2024 to August 1, 2025. I hereby release Brookville Road Community Church, its staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during these activities. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me to consent to any X-ray examination; medical, dental or surgical diagnosis, treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible. (Parent or Guardian Signature Required)

I give permission to Brookville Road Community Church to use photographs and/or video of my above-mentioned student in publications, news releases, online and other communications related to furthering the mission of BRCC. (Parent Signature Required)

Emergency Contact Name & Phone Number (If you cannot be reached)

2024-25 Student Registration and Medical Release (Effective 8/1/24-7/31/2025)

Description

Please Fix the Following