Paradise Valley Youth Registration and Consent Form

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Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Paradise Valley Church of God. Any medical information collected here serves to authorize Paradise Valley Church of God, and its staff and volunteers, to obtain medical assistance in emergencies.

Email *

Student's Name *

Date of Birth *

YYYY

Address *

Student's Cell Number

Health Card Number *

Allergies *

Dad's Cell #

Mom's Cell #

Emergency Contact Name *

Emergency Contact # *

Does your Child have any physical, emotional, mental, behavioural concerns or limitations that we should be aware of? *

Yes

If yes, please explain:

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