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FBI - Kindergarten Through 2nd Grade
Online Registration Form
This form will register up to four students. If you have additional students to register, please submit the first four and then follow the additional students button that will appear once you have hit submit.
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Indicates required field
Student Name
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First
Last
Gender
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Male
Female
Birthdate
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Age
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2019-2020 Grade
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NAME OF SCHOOL ATTENDING
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STUDENT CELL PHONE NUMBER (IF APPLICABLE
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#2 Student Name
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First
Last
GENDER
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Male
Female
BIRTHDATE
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AGE
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2019-2020 GRADE
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NAME OF SCHOOL ATTENDING
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STUDENT CELL PHONE NUMBER (If applicable)
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#3 STUDENT NAME
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First
Last
GENDER
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Male
Female
BIRTHDATE
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AGE
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2019-2020 GRADE
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NAME OF SCHOOL ATTENDING
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STUDENT CELL PHONE NUMBER (IF APPLICABLE)
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#4 STUDENT NAME
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First
Last
GENDER
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Male
Female
BIRTHDATE
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AGE
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2019-2020 GRADE
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NAME OF SCHOOL ATTENDING
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STUDENT CELL PHONE NUMBER (IF APPLICABLE)
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PARENT OR GUARDIAN NAME
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First
Last
PARENT OR GUARDIAN NAME
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First
Last
[object Object]
ADDRESS
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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CHILD LIVES WITH
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BOTH PARENTS
MOTHER
FATHER
OTHER
IF OTHER, PLEASE EXPLAIN
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EMERGENCY CONTACT (NOT LISTED ABOVE)
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First
Last
Phone Number
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MEDICAL INFORMATION
PRIMARY PHYSICIAN
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Phone Number
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INSURANCE COMPANY
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POLICY NUMBER
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ALLERGIES / HANDICAPS / RESTRICTIONS
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MEDICATIONS
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FAITH 180 PARENT AGREEMENT POLICY AND CODE OF CONDUCT
The first evening your child attends Faith 180 youth program, you will need to read and sign our Parent Agreement Policy and Code of Conduct.
I have read and understand the above statement.
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Click here to verify
CONSENT AND RELEASE
As parent or legal guardian of the student named above, understand and herby agree to assume all risks which may be encountered during said activity, including activities preliminary and subsequent thereto and do herby agree to hold Faith Christian Church and its agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my student or property and do hereby consent to any hospital, medical or surgical care and treatment, and the administration of anesthesia, determined by a qualified physician to be necessary for the welfare of my student while said student is under the care, custody and control of Faith Christian Church and I am not reasonably available by telephone to give consent. I also give my permission for photographs to be taken during youth activities.
SIGNATURE OF PARENT OR GUARDIAN
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DATE
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Submit
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