IGNITE Student Ministries Enrollment Form 2020

Fill in as much information as possible, if not known please leave blank. There will be space at the bottom for any additional information.

Students Name

First Name

Last Name

Current Grade 2019-2020

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Parents Cell

(###)

###

####

(###)

###

####

Text?

PLEASE INDICATE WHETHER OR NOT WE CAN SEND TEXT MESSAGES TO THE PARENTS CELL PHONES.

Yes

Parents Work Phone

(###)

###

####

(###)

###

####

Church Regularly Attending

Shirt Size

Parents/Guardian's Name

First Name

Last Name

Address 2

IF DIFFERENT, OR A 2ND ADDRESS WHERE THE CHILD ALSO LIVES

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address 2 Home Phone

(###)

###

####

Emergency Contact

OTHER THAN A PARENT

First Name

Last Name

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

HOME PHONE

(###)

###

####

CELL PHONE

(###)

###

####

WORK PHONE

(###)

###

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List ALL ALLERGIES to Medicines, Food, or Environment

List Any Special Medication That Your Son/Daughter Uses

Primary Insurance Carrier

GROUP POLICY NUMBER

INSURED'S NAME

First Name

Last Name

PRIMARY PHYSICIAN

First Name

Last Name

PHYSICIANS ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DENTIST

First Name

Last Name

DENTISTS ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Any Other Information That We Might Need To Know

PLEASE PUT ANY OTHER INFORMATION THAT THERE MIGHT NOT BE SPACE FOR HERE.

Medical & Media Release

In the event of an emergency, sponsors/leaders of NERC (New Era Reformed Church) will first try to contact the parent/legal guardian, second the emergency contact listed. If no one can be reached and to assure the health and safety of the child, I hereby authorize and appoint as my attorney-in-fact, NERC and its sponsors/leaders to arrange for medical and dental care, and to give oral or written consent in my absence for medical and dental treatment including surgery deemed necessary by a licensed physician. By clicking the box I indicate my willingness to take full medical insurance responsibilities for my son/daughter and to release NERC and its sponsors/leaders from any and all liability.

YES, I do give my consent

NO, I do not give my consent

In permitting the member to participate, I am specifically granting permission to NERC to use the likeness, voice and words of the member in television, radio, films, newspaper, magazines and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purpose and activities of NERC and appealing for funds to support such activities.

YES, I do give my consent

NO, I do not give my consent

Parents Signature:

Whats Next?

NERC will require your signature (pen on paper) on the release form. The church office will print these out and they will be available for signature any time the church office is open, or special arrangements can be made if you contact the church office. You can also (BEFORE YOU PRESS SUBMIT) print the form on this page and sign it and submit it as is. If you have any questions or difficulties please contact the church office. 231-861-2501.