Woodhaven Baptist Church

4000 Kildaire Farm Road, Apex, NC 27539
919-362-0127
www.woodhaven.org

Activity Name / Date

Participant Information

Participant First Name

Last Name

Birthdate

Grade

Email

Participant Cell Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Allergies

Current Medications

Insurance Company:

Policy Number

Type your new text here.

Physician

Physician Phone

Parent Contact Information

Mother / Guardian Name

Phone Number

Email

Father / Guardian Name

Phone Number

Email

Alternate Emergency Contact

Emergency Contact Phone Number

Activity Release

I give permission for my child to attend and participate in the activity as described above. In the event of illness or injury while on this activity, I authorize an adult volunteer to consent to any medical or hospital consultation or treatment as deemed necessary. I agree to pay all costs that are associated with such services. I also give permission for my child to be a passenger in a church or personal vehicle in the activity as described above.

Date

Signature

I grant permission for my child’s image or likeness to be used on any print material, video/slide presentation, website/social media post by Woodhaven Baptist Church.

Single Choice

YES

NO

Signature

Woodhaven Baptist Church

Participant Information

Parent Contact Information

Activity Release

Office Hours

Service Times

Contact Info

Follow Us