Event Registration

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JHM Life Group 2017/2018 on Wednesday, September 13, 2017 @ 7:00 PM

1No Additional Charge 
*Birth Date:
Telephone Carrier (if available):
*Do you want to receive text msg about JH Ministry?:
*Church Student Attends (if applicable):
*School Student Attends:
*Are your students involved in any on campus ministries? ie. FCA, Bible Club:
If yes, please list.:
*First Name:
*Last Name:
*Person Student Resides with:
*Cell Phone for Parent/Guardian:
*Cell Phone is for:
*Email for Parent/Guardian:
*Email Address is for:
*Adult T-Shirt Size:
Rank your preferences. We'll try to place in groups accordingly, but can't guarantee placement.:
1st Priority:
*2nd Priority:
*3rd Priority:
Friends Name (if applicable):
(These groups are not guaranteed & based on the discretion of JHM Life Group & Leader availability.):
Leader Desired (if applicable):
*Insurance Carrier:
*Insurance Policy Number:
If HMO: Primary Care Physician:
*Date of Last Tetanus Immunization:
Does your student have any allergies? If so, please list.:
Does your student have any medical concerns? If so, please list.:
I give my permission for my student to receive over-the-counter medications (such as Tylenol, Pepto-Bismol, cough medicines) when needed.:
*Permission Given:
*Emergency Contact First Name (other than parent):
*Emergency Contact Last Name (other than parent):
*Emergency Contact Phone Number (other than parent):
(We are looking for parents who would want to help support the youth ministry by serving in the following ways.):
I would be willing to serve as: (Check one or more):
A driver for an event:
Event volunteer:
Shopper (we will reimburse your expenses):
Office help:
Event or party planning:
Drive the Shuttle (requires a Class B License):
I have stuff to lend (home, car, boat, pool, truck, towing vehicle, etc):
Please Describe:
Cooking or baking:
I would be willing to cook one (1) time per month for small group leaders (6-8 people):
Small Group Leaders Meal:
Parent Consent/Release Form The student above has my consent to attend JHM Life Groups 2017/2018, sponsored by Friends Church and to participate in the activities involved in this event. I understand and agree that neither YLFC, nor its trustees, elders, representatives, employees, or agents may be held liable in any way for an occurrence in connection with involvement in the small group activities, which may result in injury, harm, or other damages to the above student. In the event of a medical or dental emergency I authorize a representative of YLFC pursuant to the provisions of California family code 6910, to consent to medical or dental care or both for the above student. I give my permission to the attending physician to hospitalize, secure proper treatment, and to order injections, anesthesia or surgery for my student. I understand that all billings for services rendered will be sent to me as the parent/Legal Guardian and that I am responsible for the complete payment. I understand that insurance coverage is the responsibility of each family, and that church coverage begins where our personal health and accident policies terminate. Regarding transportation, I am aware that my student will be transported to and from a small group event in a church rental or private vehicle. I also give permission to photograph and videotape my student for future promotional material, including YLFC website postings, without expectation of compensation. I, also, understand that in the event of repeated misconduct, the staff is authorized to send my student home at my expense. I understand that a photocopy, facsimile, or computer version of this document shall be treated as the original. I understand my student will be contacted by their leader via phone calls, texting, and appropriate social media.:
*I Agree to Consent/Release: