Register Your Child-Emergency Medical Form

Your safety and well-being are important to us. This form is designed solely to provide our staff with essential information in case of a medical emergency during church events or activities.

The information you provide will be kept confidential and used only by authorized personnel to ensure you or your child receive appropriate care if an emergency arises.

Please complete all applicable fields carefully so we can respond quickly and effectively if needed.

Student Information

Student's Name:

Date of Birth:

Address

Parents' / Legal Guardians Name:

Relation to Student:

Parent(s) Legal Guardian(s) Grandparent(s) Aunt / Uncle Older Sibling Family Friend Other

Primary Email

This address will receive a confirmation email

Primary Phone

Secondary/Emergency Contact Name:

Emergency Contact Phone

Relation to Student

Parent Legal Guardian Grandparent Aunt / Uncle Older Sibling Family Friend Other

Electronic (Parent/Guardian) Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Medical Information

Allergies (food, medications, environmental):

Current Medications:

Relevant Medical Conditions:

Primary Care Physician:

Phone

Medical Consent & Authorization

I authorize Wayne Street Church, its staff, and designated leaders to obtain necessary medical treatment for my child if I cannot be reached. This includes hospitalization, anesthesia, surgery, and medication administration as deemed necessary by licensed medical personnel.

Electronic (Parent/Guardian) Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Photo/Media Release

I grant Wayne Street Church permission to photograph or record my child during church activities and use these images/videos for ministry-related materials (newsletters, social media, websites, presentations):

Yes - I consent No - I do not consent

Date

Electronic (Parent/Guardian) Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Register Your Child-Emergency Medical Form

Description

Please Fix the Following