2023 ANNUAL STUDENT REGISTRATION
ANDERSON FIRST CHURCH OF THE NAZARENE DEPARTMENT OF STUDENT MINISTRIES
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PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 Full Name *
Primary Address: *
Primary Phone Number: *
Secondary Phone Number: *
Primary E-mail Address: *
Parent/Guardian #2 Full Name: *
Primary Address: *
Primary Phone number: *
Secondary Phone Number: *
Primary Email Address: *
STUDENT INFORMATION
Student Full Name: *
Gender: *
Grade: *
Date of Birth: *
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School: *
Cell Phone Number: *
E-mail Address: *
Siblings Names/Grade
EMERGENCY CONTACT INFORMATION
Emergency Contact Full Name: *
Primary Address: *
Primary Phone Number: *
Secondary Phone Number: *
Primary E-mail Address: *
Emergency Contact #2 Full Name: *
Primary Address: *
Primary Phone Number: *
Secondary Phone Number: *
Primary E-mail Address: *
STUDENT MEDICAL INFORMATION
Does the student have any known allergies? *
If yes, please share:
Does the student have any medical conditions, physical or mental? *
If yes, please share:
Does the student require any medications?  *
If yes, please list and share:
AUTHORIZATIONS
  The undersigned does hereby give permission for my child (“Participant”), to attend and participate in the Ohana Youth Ministries for the 2023 year. LIABILITY RELEASE: In consideration of Anderson First Church of the Nazarene allowing the Participant to participate in youth ministry, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Anderson First Church of the Nazarene, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness (including COVID-19) or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children activity. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my student, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and/or work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said student, including expenses incurred attendant thereto. MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned student pursuant to this authorization. EARLY RETURN HOME POLICY: Should it be necessary for my child to return home due to a medical reason, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child to ride in any vehicle driven by an approved and licensed adult (21 and over) chaperone while attending and participating in activities sponsored by Anderson First Church of the Nazarene. PHOTO/ RECORDING POLICY: I understand and give consent that my child may be photographed and/ or recorded for marketing and promotional purposes by Anderson First Church of the Nazarene.  
Parent/Guardian Electronic Signature *
Date: *
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