Crossroads Registration

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender *

Male

Female

Birthday *

MM

DD

YYYY

Guardian Name *

First Name

Last Name

Guardian Phone *

(###)

###

####

Emergency Contact *

Who to contact in case of an emergency.

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Secondary Contact Phone Number

(###)

###

####

Doctor's Phone Number *

(###)

###

####

Does your child have any medical conditions? *

Yes

No

Does your child have allergies? *

Yes

No

Date of Last Tetanus Shot *

MM

DD

YYYY

Do you have Medical Insurance? *

Yes

No

Liability & Media Release *

By signing this form, the parent or guardian agrees not to hold Reality Factor, the Heritage Presbytery or its employees or volunteers liable for damages, losses, or injuries to the child or his/her property. I also give permission for youth leaders to share photos and videos over social media, the church and/or Reality Factor website and other publications. The parent or guardian understands that they are signing for the minor listed on this form.

I (the parent or guardian) agree to this Liability & Media Release.

Medical Release *

In the event that I cannot be reached in an emergency during Reality Factor, I hereby give my permission to the physician or dentist selected by the Reality Factor leadership and/or my child's church youth leader to secure proper treatment for my son/daughter as deemed necessary.

I (the parent or guardian) agree to this Medical Release.

As needed Medication Release *

I give permission for the Registered Nurse at Reality Factor to administer over the counter medications (i.e. Ibuprofen, Acetaminophen, etc.) to my child as needed.

I (the parent or guardian) agree to this Medication Release.