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Kansas City, MO Student Application First Name______________________________________ Last Name_____________________________________ Address_______________________________________________________________________________________ City______________________________________ State________________________ ZIP Code________________ Cell Phone________________________________________Email________________________________________ Gender F M 8
Yes
9
No
Date of Birth Month ____________________________Day _________ Year_____________ _
Grade 10 11
12
T-Shirt Size S M L XL XXL XXXL
Dietary Requests Dairy Free Gluten Free
Vegan
I am/not going on the extended trip (July 7-12 at Bridge of Hope Community Church)
Emergency Contact Information First Name______________________________________ Last Name_____________________________________ Contact’s Address______________________________________________________________________________ City______________________________________ State________________________ ZIP Code________________ Emergency Contact Cell Phone ___________________________________________________________________ Emergency Contact Email________________________________________________________________________ Emergency Medical Information Participant’s Insurance Company: _________________________________________________________________ Policy Type: ____________________________________________________________________________________ Policy#: ________________________________________________________________________________________ Physician Name ____________________________________Phone Number:_______________________________ Will student be bringing any prescription medication to Challenge? Yes
No
What kind and for what condition? _______________________________________________________________ ______________________________________________________________________________________________ List any known allergies and reactions:____________________________________________________________ ______________________________________________________________________________________________ Registrations are non-refundable but are transferable to another person in our group.
Permission Form We will be spending the day at Worlds of Fun on July 7, 2018 I give permission for my child First Name_________________________ Last Name_______________________ to attend the extra activity. In case of an emergency, I give permission for my child to receive medical treatment. In case of such an emergency please contact. Emergency Contact Name_______________________________________________________________________ Emergency Contact’s Signature__________________________________________________________________ Phone Number________________________________________Date_____________________________________
Extended Trip (July 7-12) Permission Form (Grades 10, 11, and 12) I am/not attending the extended trip
Yes
No
I give permission for my child First Name_________________________ Last Name_______________________ to attend the Extended Trip volunteering at Bridge of Hope Community Church. In case of an emergency, I give permission for my child to receive medical treatment. In case of such an emergency please contact. Emergency Contact Name_______________________________________________________________________ Emergency Contact’s Signature__________________________________________________________________ Phone Number________________________________________Date_____________________________________