Student Activity Waiver for Summer 2022 to Spring 2023

Jr High Ministry of Calvary Chapel Costa Mesa

1Student Info > 2Release Form
Student's Name Student's Name * First Last
Date of Birth Date of Birth / MM / DD YYYY
Cell Phone Cell Phone * - ### - ### ####
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Gender *
Grade *
Email *
School Attending *
Church Attending *
Parent/ Guardian Information
Parent or Guardian's Name Parent or Guardian's Name * First Last
Cell Phone Cell Phone * - ### - ### ####
Parent or Guardian's Email Address *
Parent/ Guardian 2 Name (Optional) Parent/ Guardian 2 Name (Optional) First Last
Cell Phone Cell Phone - ### - ### ####
Parent or Guardian's Email Address
Student's Health History

To protect your child from possible embarrassment, but not exclude him/her from participation, please select any health concerns that we should be aware of.
Check all that are applicable

Check all that are applicable Frequent Ear Infections Heart Defect/Disease Convulsions Diabetes Bleeding/Clot Disorder Sleep Walking Bed Wetting Asthma Hay Fever Allergic to Insect Stings Allergic to Penicillin Other Other
Diseases:

Diseases: Chicken Pox Measles German Measles Mumps Other Other
Any allergies? *
If yes, which one(s):
If your child has Asthma, does your child travel with an inhaler?
Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? *
If yes, please explain:
Medication Information:
If necessary, please provide information of current medication
Emergency Contacts

Parents/Guardians will be contacted first with above information! Please provide 2 additional emergency contacts
Emergency Contact Name Emergency Contact Name * First Last
Relationship *
Phone Phone * - ### - ### ####
Emergency Contact Name Emergency Contact Name * First Last
Relationship *
Phone Phone * - ### - ### ####
Insurance Information
Parent's Employer
Insurance Company
Policy Number
Name of Policy Holder

Student Activity Waiver for Summer 2022 to Spring 2023

Student Activity Waiver for Summer 2022 to Spring 2023

Parent/ Guardian Information

Student's Health History

Emergency Contacts

Insurance Information