Summer Ministry Registration Form • Stow Alliance Fellowship

Child Information

FIrst Name *

Last Name *

Which Camp Will you be attending? *

Date of Birth *

Gender *

Grade Just Completed *

Allergies (food, medical, etc..) *

Parent Information

First Name *

Last Name *

Home Address *

Home City *

Home State *

Email Address *

Mobile Number *

Emergency Contact (other than parents)

Name : First and Last *

Phone Number *

Insurance Company and Policy Number *

Preferred Doctor *

Phone Number *

Preferred Hospital *

Medical Release Statement

Medical Release Statement I understand that, in the event of a medical emergency while my children is under the care of Stow Alliance and its representatives and I am not available, Stow Alliance will call for emergency medical treatment. I hereby consent to and will be responsible for any reasonable medical treatment as deemed necessary by a licensed physician. I understand that every possible attempt will be made to contact me in the event of an emergency. I agree to hold the physician, medical facility, Stow Alliance and its representatives free and harmless of any claims, demands or suits for damages arising from the authorization and provision of such medical treatment.

Purpose and Intent

Stow Alliance is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our church. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel. If you wish Stow Alliance Fellowship to limit the information collected, or to view your childs information, please contact us.

Photography

I agree that pictures or videos of activities, that may include my child, might appear on the church website, Children's Ministry Facebook page, or in other church media. If at any time you wish to remove this authority please contact church office.

Parent/Guardian Permission

By typing my name here, I am stating I have read and agree to all the information above and I am the legal parent or guardian of the children listed below *