Student Name *

First Name

Last Name

My student is attending: *

Please check all that apply.

Club (grades 5-8)

Senior High Youth Group (8-12)

Parent 1 *

First Name

Last Name

Parent 2

First Name

Last Name

Student Birthdate *

MM

DD

YYYY

Parent Preferred Phone *

(###)

###

####

Student Phone

If available for texting

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Phone *

(###)

###

####

Physician Phone *

(###)

###

####

Photo/Video Release *

I hereby give permission for my child to be photographed and/or video-recorded while participating in BeFree activities, and for those images to be used on the church website or other promotional materials (children will not be identified by name).

I do not give permission for my child to be photographed or video-recorded.