Warehouse 2022-2023 Student Information Form
Please fill in STUDENT information below unless otherwise indicated. If you have multiple students in the ministry, please fill out separate forms for each of them.
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STUDENT Name (first and last) *
STUDENT Email *
STUDENT Phone number *
PARENT Email(s) *
PARENT Phone Number(s) *
STUDENT Birthday *
MM
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DD
/
YYYY
STUDENT Address *
Grade in Fall 2022 *
Health Considerations - please list any allergies or other specific health considerations *
Health Insurance - Please list carrier and policy number *
Primary Care Physician - please list name and phone number *
Emergency Contact 1 - please list name and phone number for primary emergency contact *
Emergency Contact 2 - please list name and phone number for secondary emergency contact
Release for health care - In the event of an emergency or non-emergency situation in which medical treatment is required as as result of participation in the activities of Warehouse Student Ministries and/or Decorah Covenant Church during the period of time between June 1, 2022 - May 31, 2023; every reasonable effort will be made to contact the persons listed above. If unsuccessful in contacting the persons listed, consent is given for treatment by competent medical personal.  Further, consent is given to youth directors or volunteers of Decorah Covenant Church to hospitalize, secure proper treatment for, and to administer injection, anesthesia, or surgery (under recommendation of qualified medical personnel). *
Required
Signature of Primary parent(s) or guardian(s) - please type name *
Indemnification and Release - By accepting this document, you agree that you are the legal parent(s)/guardian(s) of the Student listed on this form and consent to the following: I consent to the said minor attending activities of Warehouse Student Ministries, the student ministry of Decorah Covenant Church of Decorah, IA, that are scheduled from June 1, 2022 - May 31, 2023, and which will include various modes of transportation such as bus, train, personal automobile, etc. I/we hereby further consent to medical care and treatment being rendered or furnished to said minor in the even such circumstance should arise, and prompt notification of same will be given to the undersigned. I/we, the undersigned, hereby agree to indemnify and hold harmless Decorah Covenant Church and any individual in his or her capacity as board member, officer, director, trustee, pastor, counselor, or teacher from and against all claims, damages, losses, and expenses, including attorney's fees, arising out of or resulting from participation of said minor in the activities indicated above. *
Required
Signature of Primary parent(s) or guardian(s) - please type name *
Social Media/Website Permission - Unless notified, in writing, to the contrary, Decorah Covenant Church has permission to use my child's name, likeness, image, voice and/or appearance, which may be embodied in any photos, videos, digital images, and the like, taken or made during any Church activities. Please note that when we post pictures on social media or the website we do not post your child's name. I understand and agree to the above agreement. Please check the appropriate box and type your name below *
Required
Signature of Primary parent(s) or guardian(s) - please type name *
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