THE SUMMER CLUB APPLICATION | Community Advance

Name*

First Last

MALE
FEMALE

Grade*

School*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian*

First Last

Relationship to student*

Phone*

Email*

Emergency Contact*

First Last

Relationship to student*

Phone*

MEDICAL RELEASE FORM*

PARENTAL AGREEMENT

I agree to indemnify and hold harmless those persons of Community Advance, Northwest Baptist Church, their employees, all personnel including consultants and volunteers participating in or associated in any manner with this event from claims of damages, liabilities, injury, expense or loss occurring out of its activities. In case of an accident or need of medical attention, I give my permission for The Summer Club and its staff and/or affiliates to take my child to a doctor and/or emergency facility. It is understood that all expenses incurred by any treatment will be the responsibility of the parent/guardian.

DIGITAL SIGNATURE*

First Last

Date*

Physician/Clinic's Name and Phone #*

List any allergies or medication:*

Insurance Company*

Procedures & Guidelines*

I agree to the privacy policy.

-No vulgar or hateful language
-No public displays of affection
-No arguing or fighting
-No bullying
-Show respect to staff and volunteers

If the above behavior guidelines are not followed, the student will be given a warning. If an issue has to be addressed again by the director, the parent/guardian will be called immediately to come pick up the student. Continuation in the program will be evaluated on an individual basis.

There is zero tolerance for bringing drugs, alcohol, or weapons of any kind on the premise. If a student is found to be in possession, the police and parent/guardian will be notified and the student will not be allowed to return.

Parental permission form*

Parental agreement

-I give permission for the above named student to travel with van drivers, staff and other volunteers
-I give permission to use the above named student in photos, videos and social media for promotional purposes.
-I agree the above named student will be picked up from The Summer Club by 5:00 PM and 3:00 PM on Fridays
-I give my student permission to participate in life-skill presentations and biblical devotions.

Student*

I have read and agree to adhere to The Summer Club procedures and guidelines.

Digital Signature*

First Last

Date*

Parent/Guardian*

I give the above named student permission to participate in all activities and programs at The Summer Club and agree to the terms of Community Advance.

Digital Signature*

First Last

Date*

Email

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