Centerpoint Registration If you are not intending to register with Centerpoint, please go back to the Student Registration page and select the church youth group you are with. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Grade * 6 7 8 9 10 11 12 Leader Age * Gender * Male Female Birthday * MM DD YYYY T Shirt Size and Style * Short Sleeve Small Short Sleeve Medium Short Sleeve Large Short Sleeve XL Long Sleeve Small Long Sleeve Medium Long Sleeve Large Long Sleeve XL Short Sleeve Youth Large Short Sleeve Youth Extra Large Long Sleeve Youth Large Long Sleeve Youth Extra Large Guardian Name * First Name Last Name Guardian Phone * (###) ### #### Guardian Email * Emergency Contact * Who to contact in case of an emergency. First Name Last Name Relationship to Reality Factor Attendee * Emergency Contact Phone Number * (###) ### #### Secondary Contact Phone Number (###) ### #### Doctor's Name * Doctor's Phone Number * (###) ### #### Does your child have any medical conditions? * Yes No If yes, list: Does your child have allergies? * Yes No If yes, list allergies and treatments List the name and dosage of any medication that MUST be taken. These must be put in a separate bag and labeled and given to your leader at check-in. Students cannot administer their own medication. Date of Last Tetanus Shot * MM DD YYYY Do you have Medical Insurance? * Yes No Policy # Policy Provider Liability & Media Release * By signing this form, the parent or guardian agrees not to hold Reality Factor, the Heritage Presbytery or its employees or volunteers liable for damages, losses, or injuries to the child or his/her property. I also give permission for youth leaders to share photos and videos over social media, the church and/or Reality Factor website and other publications. The parent or guardian understands that they are signing for the minor listed on this form. I (the parent or guardian) agree to this Liability & Media Release. Medical Release * In the event that I cannot be reached in an emergency during Reality Factor, I hereby give my permission to the physician or dentist selected by the Reality Factor leadership and/or my child's church youth leader to secure proper treatment for my son/daughter as deemed necessary. I (the parent or guardian) agree to this Medical Release. As needed Medication Release * I give permission for the Registered Nurse at Reality Factor to administer over the counter medications (i.e. Ibuprofen, Acetaminophen, etc.) to my child as needed. I (the parent or guardian) agree to this Medication Release. Registration Complete! Make sure you fill out the North Bay Medical Form (contact your youth leader) as well as payment to your church.
