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Hillcrest Children/Student Registration
*
Indicates required field
Parent's Name (s)
*
First
Last
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Primary Cell or Home Phone Number
*
Other Cell Phone Number
*
Email
*
Email
*
Family Status
*
Married
Single Parent
Divorced
Separated
Widow
Other
Persons allowed to pick up your child:
*
Only parents listed above may pick up my child(ren).
Please allow the following to pick up my child(ren) in my absence.
Name
*
First
Last
Relationship
*
Name
*
First
Last
Relationship
*
Children
Child's Name
*
First
Last
Birth Date
*
Grade
*
Gender
*
Male
Female
Student Cell Phone
*
Receive Texts
*
Yes
No
Child's Name
*
First
Last
Birth Date
*
Grade
*
Gender
*
Male
Femal
Student Cell Phone
*
Receive Texts
*
Yes
No
Child's Name
*
First
Last
Birth Date
*
Grade
*
Gender
*
Male
Female
Student Cell Phone
*
Receive Texts
*
Yes
No
Child's Name
*
First
Last
Birth Date
*
Grade
*
Gender
*
Male
Female
Student Cell Phone
*
Receive Texts
*
Yes
No
Child's Name
*
First
Last
Birth Date
*
Grade
*
Gender
*
Male
Female
Student Cell Phone
*
Receive Texts
*
Yes
No
Confirmation Signature
Activities Consent
By marking "YES," I confirm that all of the information I have provided above is accurate and complete to the best of my knowledge and that this will serve as my signature.
*
YES
As the parent/legal guardian of the child(ren) listed above, by marking "YES" below, I hereby consent for my child(ren) to attend and participate in all Hillcrest activities, and I understand that this will serve as my signature.
*
I do not consent at this time.
YES
Yes, with the exclusions listed below.
Medical Information
This information is required for all activities outside of Sunday School, or when parents are not present.
Physician's Name
*
Clinic
*
Phone Number
*
Insurance Company
*
Policy Number
*
Allergies
*
Please be specific for each child or type "none" if none of your children have allergies.
Other Medical Information
*
I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment.
As parent or legal guardian of my child, I am responsible for the health care decisions of my child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child is legally sufficient and that no consent from any other person is required by law.
By marking "YES" below, I agree to the two previous statements and understand that this will serve as my signature.
*
YES
I do not agree at this time.
Transportation Consent
As the parent or legal guardian of my child/ren, I hereby consent for my child/ren to be transported to activities off of Hillcrest’s campus by Hillcrest’s paid staff, student ministries’ volunteers, children’s ministries volunteers and/or Powerhouse volunteers. By marking "YES" below, I agree to this statement and understand that it serves as my signature.
Transportation Consent
*
YES
I do not agree at this time.
Emergency Contact Information
This information is recommended for all registered children and
required
for all children participating in activities without a parent present and for all students participating in 180 activities. Please provide name and phone number of
someone other than parent and/or guardian
previously listed.
Name
*
First
Last
Phone Number
*
Name
*
First
Last
Phone Number
*
Submit
Home
About
Discover Hillcrest
Giving
SCRIP
Contact
Staff
Elders
Media
Ministries
Adults
>
Small Groups
Students
Children
>
VBS
Missions
Adoption & Foster Care
Cleveland Elementary
Ethiopia
Other Missions
Events
Upcoming Events
Event Calendar
Messages
Sunday Sermons
Sunday's Bulletin
Daily Devotional
