Activity Form

High School 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

Activity Form

Activity Form

Parent/ Guardian Information

Student's Health History

Emergency Contacts

Insurance Information