City on a Hill Community Church - Education Co-op for New Families

Parent/Guardian Info

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Child Info

First Name

Last Name

Date of birth

Gender

Please list any medical information we should know about your child(ren):

Please list your child(ren)'s grade level(s):

Emergency Contacts

Please provide 3 emergency contacts:

Contact 1 Name:

Phone Number

Contact 2 Name:

Contact 2 Phone Number

Contact 3 Name:

Contact 3 Phone Number

Statement of Agreement

I have read and agreed to the policies and procedures put forth by the CHCC Educational Co-op.

I have read and agree to the Core Doctrine from City on a Hill Community Church.

Medical Waiver

Minor Participation Authorization and Consent to Emergency Medical Treatment

I, the undersigned, certify that I am the parent or legal guardian of the child(ren) listed on my CHCC Education Co-op enrollment form (hereafter the “minor child(ren)”). I hereby give my consent to have my minor child(ren) participate in the City on a Hill Community Church Education Co-op (hereafter “the activity”). I recognize that there are risks involved in participating in this activity and hereby assume all risk of injury, harm, damage, or death to my minor child(ren) in connection with his/her participation in this activity. To the fullest extent permitted by law, I release City on a Hill Community Church, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless City on a Hill Community Church, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child(ren)’s participation in the activity. Further, being the parent or legal guardian of the minor child(ren), I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child(ren). I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child(ren). As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child(ren) and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child(ren). Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage.

By digitally singing your name below, you are confirming your child's enrollment into the CHCC Education Co-op and that the information on these forms is correct.

Registration for New Co-op Families

Parent/Guardian Info

Child Info

Emergency Contacts

Statement of Agreement

Medical Waiver

Service Time & Location

Contact Info

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