RUSH STUDENT REGISTRATION (Sheboygan) • Crossroads Community Church

This "RUSH Student Registration" form should be completed by parent/guardian. Thank you!

STUDENT Information

Student First Name *

Student Last Name *

Gender *

Date of Birth *

Mobile Number

Email Address

School Name *

School Grade *

Allergies (please list any food or environmental allergies that we should be aware of)

RUSH Student Church Affiliation *

RUSH Student Other Church Name (if applicable)

Home Address Of Student

Home Address *

Home City *

Home State *

Home Zip Code *

Parent/Guardian Information

Mother's First Name

Mother's Last Name

Mother's Phone Number

Mother's Email Address

Father's First Name

Father's Last Name

Father's Phone Number

Father's Email Address

Do parents reside together in the same household? (This question helps with our database and how we group children with parent(s).)

If child does not live together with both parents, which parent should be considered the key contact? (please type name)

Important: Parental/Guardian Consent Forms

The following information is required in order to process this registration form. We ask that parent/guardian read through each waiver, and choose the appropriate response. Thank you!

I am the parent/guardian and I have the legal authority to sign these waivers and permissions for the student(s) that is being registered for RUSH. (PARENT/GUARDIAN-please type your name in the line below.)

Medical Waiver

The student(s) listed on this form has/have my permission to participate in all RUSH Youth Group activities and events organized and/or hosted by Crossroads Community Church. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Crossroads Community Church and its staff and/or volunteers of any liability against personal losses of myself/named child. I understand that my consent/permission is granted for the entire duration of time that my child(ren) participates in RUSH youth group activities.

I/We have legal custody of the participant(s) named on this form, a minor(s), and have given our consent for him/her/them to participate in all RUSH Youth Group activities being organized by Crossroads Community Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Crossroads Community Church, its employees, agents, and volunteer workers from any and all liability for any illness, injury, loss, or damage to person or property that may occur during the course of our child(ren)’s involvement. In the event that he/she is showing symptoms of an illness/injury that could require the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary. In the event testing is recommended or treatment is required from a physician and/or medical personnel designated by Crossroads Community Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider.

RUSH Student Medical Waiver *

Medical waiver permission is granted.

Permission To Transport Off-Site

I hereby grant permission to Crossroads Community Church (including but not limited to RUSH leaders and/or volunteer parents) to transport my child(ren) off-site for activities such as but not limited to Scatter Nights, service projects, small group gatherings and/or leader/student meetings. I understand that my permission is granted for the entire duration of time that my child(ren) participates in RUSH youth group activities.

RUSH Student Off-Site Permission *

Media Release

I hereby grant permission to Crossroads Community Church & RUSH Youth Group to us my child(ren)’s photo on their website(s) or in any other official publications, promotional materials and videos, and I acknowledge Crossroads Community Church’s right to crop or treat the photo at their discretion. I also understand that once the image is posted on a website, Facebook or newsletter, the image can be downloaded. Therefore, I agree that Crossroads Community Church is not held responsible for such occurrences. I understand that my permission is granted for the entire duration of time that my child(ren) participates in RUSH youth group activities.

RUSH Student Media Release *

Ibuprofen & Tylenol

Periodically students ask for ibuprofen and/or Tylenol. Do you give Crossroads Community Church (RUSH leaders and/or volunteer parents) permission to give your child(ren) Ibuprofen or Tylenol if they request it?

RUSH Student Permission for Ibuprofen &Tylenol *

By checking this box, you are verifying that I (parent/guardian) understand, agree and personally give my consent to all these waivers. *

Is there any other info you want to share that would be helpful for us to know?