Registration Release Form

If you would like to fill out an online Medical Release form, fill out here!

Student's Name*  
Date of Birth*  
Grade Entering  
Student 2 Name  
Student 2 Grade Entering  
Student 2 Birthdate  
Student 3 Name  
Student 3 Grade Entering  
Student 3 Birthdate  
Student 4 Name  
Student 4 Grade Entering  
Student 4 Birthdate  
Zip Code*  
Home Phone*  
Mother's Name*  
Mother's Home/Cell Phone  

Email Address

Is email a good way to communicate with you?  
Father's Name*  
Father's Work/Cell Phone*  
(Insurance information needed for 5th grade - 12th grade only)  
Insurance Company Name*  
Policy #*  
Group #  
Is your child in general good health and able to participate in all activities? Yes or No*  

If no please list

Does your child have allergies to medication or food? ¬†Yes or No*  
If yes, please list  
Parent/Guardian Signature  

In signing this consent form, I hereby certify that the above information is correct and grant my permission for the release of medical records in the case of accident during an activity.  In case of medical emergency, I understand that every effort will be made to contact parent/guardian of child. In the event I cannot be reached, I hereby grant permission for the adult leaders of Vriesland Reformed Church to obtain emergency medical care and proper treatment for my child named above, at my expense. Parent/Guardian agrees on behalf of both parents/guardian and the child, to indemnify, defend, and hold harmless the ministry, and its agents, employees, volunteers, and other representatives for injury arising while child is in their care. I also give permission for the use of photographs including my son/daughter to be used in church publicity.

Verify Words*