Please complete the registration/Medical form below

Child's Name *
Child's Name
Parent/ Caregiver Name *
Parent/ Caregiver Name
Emergency Contact Number *
Emergency Contact Number
Cell Phone Only
If none, please mark N/A
Special Needs
If your child requires special needs please specify below:
Medical Form (Required for Registration)
Please list Insurance Type, Member # and Group #
If none, please mark N/A
In consideration of the said Calvary Chapel Coastlands permitting our child to participate in the aforesaid activity, we hereby agree to indemnify and save harmless said Calvary chapel Coastlands, its officers, volunteers, employees and agents against any and all claims for loss and liability incurred by or caused to our child as a result of said activity. If I cannot be reached, I grant permission to any physician or emergency medical personnel to render any emergency medical treatment deemed necessary.