Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Gender *

Male

Female

Student Phone Number

(###)

###

####

Primary Contact Name

First Name

Last Name

Relationship

Mother

Father

Other

Primary Contact Phone

(###)

###

####

Preferred Method of Contact

(For Social Reasons)

Call

Text

Email

Other

Secondary Contact Name

First Name

Last Name

Relationship

Mother

Father

Other

Secondary Contact Phone

(###)

###

####

Preferred Method of Contact

(For Social Purposes)

Call

Text

Email

Other

Physician Phone

(###)

###

####

Is your child a:

good swimmer

fair swimmer

non-swimmer

By entering your name(s) and checking the boxes below, you agree that this form is an electronic record executed by you using your electronic signature, and you acknowledge and agree to all of the terms set forth.

I Agree

For your information, we expect each student to conform to these rules of conduct:

No possession of alcohol, drugs or tobacco. No students can drive during youth activities. No fighting, weapons, fireworks, lighters, or explosives. No offensive or immodest clothing. No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters. Participation with the group is expected. Respect property. Respect one another, staff and adult leaders. Respect and comply with event schedules.

I Agree

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I understand there are inherent risks involved in any ministry event, athletic event or adventure trip and I assume the risks associated with them. I agree to abide by the stated personal limitations and code of conduct.

I Agree

I, the undersigned, have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Virginia Beach Community Chapel.

I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release and agree to indemnify the Church, its pastors, employees, agents and volunteer workers from any and all liability for injury, loss, or damage to person or property that may occur during the course of my child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home at my expense should they become ill or if deemed necessary by the student ministries staff member.

I Agree