Kingdom Club Student Leader Application

Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #1 Email

This address will receive a confirmation email

Parent/Guardian #1 Phone

Address

Parent/Guardian #2 Name

Parent/Guardian #2 Email

Parent/Guardian #2 Phone

Church Home (If any)

I give permission for my child(ren)'s picture to be used anonymously in Waypoint publications for ministry purposes.

Yes No

Student #1

First Name

Last Name

Student's Email

Student's Cell

Gender

Date of Birth (MM/DD/YY)

Grade 2023-2024 School Year

Student's allergies, health concerns, or special needs

Student #2

First Name

Last Name

Student's Email

Student's Cell

Gender

Date of Birth (MM/DD/YY)

Grade 2023-2024 School Year

Student's allergies, health concerns or special needs

Student #3

First Name

Last Name

Student's Email

Student's Cell

Gender

Date of Birth (MM/DD/YY)

Grade for 2023-2024 School Year

Student's allergies, health concerns or special needs

Child's allergies, health concerns, special needs

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Relationship to Student

Parental Permission for Participation and for Emergency Treatment

For legal and insurance purposes, parents are required to give permission for their children to participate in church-sponsored activities. I understand that my child(ren) will be under adult supervision at all times. Participants or parents of children participating in church-sponsored activities covered by church insurance are financially responsible for medical, hospital and pharmeceutical expenses above the amount paid by the insurance company for any injury or illness sustained during activities sponsored by the church. In the event of accident or illness, I give my permission for emergency treatment by qualified medical personnel for my child(ren.)

Electronic Signature*

*By entering my name in the box above, I am providing my digital signature on this Form.

Kingdom Club Student Leader Application

Description

Please Fix the Following