DNow Registration

Participant Information
Name*
First Last
Gender*
- Male
- Female
Grade*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Student Cell
T-shirt Size*
Adult sizes
List two friends you would like to be placed with.
We do our best to make sure you are with at both of these friends, but due to allergies and housing it is not always possible
Parent/Guardian Information
Parent/Guardian 1 Name*
First Last
Parent/Guardian 1 Cell*
Parent/Guardian 2 Name*
First Last
Parent/Guardian 2 Cell*
Health and Insurance Information
Health Insurance Company*
Policy Number*
Group Number
In whose name is the insurance?*
Family Doctor Name*
Family Doctor Phone
Medical concerns we need to know:*
If none, please indicate.
Special dietary needs:*
If none, please indicate.
Allergies:*
If none, please indicate.
Current Medications:*
If none, please indicate.
Do you wear contact lenses?*
- Yes
- No
Date of last tetanus vaccination:*
Date Format: MM slash DD slash YYYY
Height
Weight
Date of Birth*
Date Format: MM slash DD slash YYYY
Consent
Consent*
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I (we) cannot be reached, I give my permission for medical treatment to the physician or dentist selected by the adult leaders of the CrossRoads Church.

I understand that my insurance coverage will be used as primary coverage in the event a medical emergency occurs.

I understand all reasonable safety precautions will be taken at all times by the church and its agents during the events and activities. I agree not to hold the church leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred.

For promotional and publicity purposes, I will allow my youth’s picture to be taken and used. Names will not be used to identify persons in the pictures.
I understand and consent.
Electronic Signature*
In agreement to the above registration and as the legal parent or guardian of the student listed above, please enter your first and last name in the box below to serve as an electronic signature.

DNow Registration

Participant Information

Parent/Guardian Information

Health and Insurance Information

Consent