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
*
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?
*
If yes, list:
Does your child have allergies?
*
If yes, list allergies and treatments
Date of Last Tetanus Shot
*
MM
DD
YYYY
Do you have Medical Insurance?
*
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.
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.
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.
