GATEWAY HIGH SCHOOL

We are so glad you've decided to join us for a Real Essentials event in Clovis!

Please take a few minutes to complete this registration form. Once we've received your form, we'll be in touch with more details.

Registering for: *

ATTENDEE INFORMATION

Student Name: *

First

Last

Gender: *

Female
Male
Other

Age *

Grade *

Address: *

Address Line 1

City

State

Zip Code

Student Phone:

Parent/Guardian Phone: *

Student Email:

Parent Guardian Email: *

Please list any food allergies or dietary restrictions.

Has the attendee experienced foster care or adoption?

Does the attendee have any medical conditions, disabilities, or behavioral issues the staff should be aware of?

Please provide a brief explanation and helpful tips for interacting with the attendee

PHOTO RELEASE

Photos taken at this event may be published to our website, social media accounts, or other promotional materials. Do you consent for images and/or videos of your student to be used for marketing and/or promotional purposes? (copy)

EMERGENCY CONTACT

In case of emergency, please contact: *

First

Last

Emergency Contact Phone: *

Medical Insurance/Policy Company Name:

Relationship to Attendee: *

Policy/ID Number:

RELEASE OF LIABILITY

I, the undersigned, as the legal guardian of the attendee, do consent to his/her involvement in the Real Essentials youth program sponsored by The Worship Centre Church. If any injury or illness should occur while participating in youth program related activities, I do not hold The Worship Centre Church, its youth program, any of its leadership, or its associates responsible in any way for any incident or accident that may occur while participating in youth program.

I have read and fully understand the above statement and give my permission for my student to participate in the Real Essentials youth program and its activities.

Parent/Legal Guardian Name: *

Parent/Legal Guardian Signature: *

Clear Signature

Today's Date *