Last Name_________________________________ First_____________________ Init.____
Address__________________________________ City/State/Zip______________________
Birthdate (Month/Day/Year)______________________ SSN _________________________
PARENTS:
Father' s name _________________________________ Occupation___________________
Home Ph ____________Father' s address ________________________________________
Bus Ph______________
Mother' s name ________________________________ Occupation___________________
Home Ph____________Mother' s Address _______________________________________
Bus Ph______________
MEDICAL:
Child' s Physician___________________________________Bus Ph ___________________
Health Insurance Co.________________________________Policy #___________________
Date of last Tetanus shot (Month/Year) __________________________
List ANY medical problem or prohibition your child has:______________________________
_________________________________________________________________________
Person to notify in case of emergency:
Name ______________________________________________Phone_________________
I hereby give my consent to and authorize my minor child above-named to participate in all events
conducted by St. John's Presbyterian Church of Reno, Nevada ("the Church" ). I further authorize
my minor child to travel with parents of other children or em ployees of the Church in private or
other vehicles to any such event. I agree on my own behalf and on behalf of the minor child that
should we par ticipate in any such event, we will conduct ourselves in a proper and or derly fashion,
will follow the direction of the person in charge, and will abide by all the rules of the church.
As parents and/or guardians we further agree to waive any claim against the church or any of
its affiliate organizations except to the extent my child or I are eligible for compensation under
any existing insurance coverage. I further agree to indemnify and hold the church harmless for
any property damage or per sonal injuries which my minor child may cause as a result of
his/her negligent or intentional conduct.
This consent is to be signed by both par ents unless, pursuant to an order of a court of competent
jurisdiction, legal custody of the minor child has been granted to one parent. In the event a legal
guardian has been appointed by a court of competent jurisdiction, please indicate below your signature.
Mother________________________ Witness____________________ Date____________
Father________________________ Witness_____________________Date____________