2017 & 2018 Registration and Permission Slip Student Name First Last GradeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student Birth DateHome PhoneParent/Guardian Name First Last Parent/Guardian Email Parent/Guardian Cell PhoneParent/Guardian Name First Last Parent/Guardian Cell PhoneParent/Guardian Email Present church affiliation:Does your child have any allergies or dietary restrictions?My child’s doctor is:Doctor's Phone:Health Insurance Company:Policy #:Any other information you would like us to know about your child or family:Help us share the love of Jesus Christ with our youth by: (check all that apply) Serving on the Hospitality Team that hosts our meals each week Driving for mission or fun nights Helping with fundraising Participating in special events My child (listed above) has permission to participate in all activities on the Allentown Presbyterian Church campus, including off-campus events, such a mission nights, special events and retreats. I understand my child will be traveling, either by foot or vehicle, with a church-approved Shepherd. I grant permission to the Allentown Presbyterian Church to take and publish photographs, video, voice recordings, or any other likeness of my child for use in materials, both print and digital, that may be presented in the public domain for the purpose of promoting APC’s programs and ministries. In the event of a medical emergency, I understand that I will be contacted immediately to authorize care. If I cannot be reached, I authorize Crossroads Youth & Young Adult Ministry staff to approve care.Date * If you there are any medical issues that we should know about, please contact Jenna Brown at 609-256-0199.