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Watch
Ministries
Storehouse
Northstar Kids
Northstar Youth
Northstar Ladies
Northstar Men
About Us
What We Believe
Service Info
Location
Downloads
Contact Us
Give
Watch
Ministries
Storehouse
Northstar Kids
Northstar Youth
Northstar Ladies
Northstar Men
About Us
What We Believe
Service Info
Location
Downloads
Contact Us
Give
EVENT NAME
*
Example: VBS, Kid's Camp, Youth Trip, etc.
PARTICIPANT INFORMATION
Name
*
First Name
Last Name
Date Of Birth
*
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Last Grade Completed
*
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Gender
*
Girl
Boy
Friend Request (Limit 2)
PARENT/GUARDIAN INFORMATION
Parent's Name
*
First Name
Last Name
Relationship To Child
*
Mother
Father
Guardian
Parent's Phone
*
(###)
###
####
Parent's Email
*
Parent's Name
First Name
Last Name
Relationship To Child
Mother
Father
Guardian
Parent's Email
EMERGENCY INFORMATION
Do you carry family medical/hospital insurance?
*
Yes
No
Insurance Carrier Name
Insurance Group Policy Number
Name Of Policy Holder
First Name
Last Name
Policy Holder Phone Number
(###)
###
####
SECONDARY EMERGENCY CONTACT
Secondary Emergency Contact
*
In case of an emergency, the parent or legal guardian will be contacted immediately. If we are unable to reach you, please list a secondary contact person.
First Name
Last Name
Secondary Emergency Contact Phone
*
(###)
###
####
Relationship To The Child
*
MEDICAL INFORMATION
Physical Limitations
*
Yes
No
Mental Limitations
*
Yes
No
Peanut Allergy
*
Yes
No
Asthma
*
Yes
No
Convulsions
*
Yes
No
Heart Defect
*
Yes
No
Diabetes
*
Yes
No
Red Dye Allergy
*
Yes
No
Lactose Intolerance
*
Yes
No
Current Immunization
*
Yes
No
Does the participant have any other conditions that we should know about?
Are there any activities from which this participant should be restricted?
MEDICATION
Does this participant take any prescription medications? If yes, please send in the original prescription bottle stating instructions.
*
Yes
No
What is the reason for the medication?
Is this participant allergic to any medication?
*
Yes
No
If yes, please list the medications.
PERMISSIONS
May we have permission to photograph your child?
*
Yes
No
May we have permission to use your child's photograph for promotional purposes?
*
Yes
No
THIS FORM MUST BE SIGNED BY THE PARTICIPANT'S LEGAL GUARDIAN.
As the parent or legal guardian of the participant, I authorize he/she to attend the event and to engage in all activities. I agree personally and on behalf of minor to release Northstar Church, Inc. and their legal representative and employees from all liability from harm to minor or minor's personal property resulting directly or indirectly from minor's participation in the event, and to indemnify Northstar Church, Inc. against any such liability. I authorize administration of a tetanus shot or other medical treatment, if deemed necessary, and I agree to release and indemnify Northstar Church, Inc. against all liability and cost for treatment.
*
First Name
Last Name
Checking "Yes" serves as your E-Signature for this release.
*
Yes, this serves as my E-Signature for the release form.
Decline the E-Signature and as a result the participant will not be attending the event.
Today's Date
*
MM
DD
YYYY
Thank you!
