Student's Name (Attendee)

Student's Last Completed School Grade

Student's Date of Birth

Parent/Guardian Name

Parent/Guardian Address

Parent/Guardian Home Phone Number

Parent/Guardian Cell Phone Number

  Do you text?

Parent/Guardian Email

Parent/Guardian Work Phone

Names of individuals besides yourself who are authorized to pick up your child. Please understand we will ONLY release your child to you or a specific person you authorize beforehand.

Please list any medications, health concerns, or allergies:

Special instructions or information we need to know:

Best Phone Number to Contact in Case of Emergency:

Emergency Contact if Parent/Guardian Is Not Available (Name and Number):

  I, the parent or guardian of the above-named child, acknowledge that Soccer Skills Bible Camp (SSBC) provided by Parkview Baptist Church is administered by volunteers and knowledgeable soccer skills personnel. Parkview Baptist Church SSBC does not guarantee that your child will grow in all areas of soccer skills. Parkview Baptist Church will not be held liable for any possible injury. I understand that Parkview Baptist Church SSBC is a Christian organization therefore Christian values will be taught and upheld as part of daily activities. I give my child permission to be treated by a physician in the event of an emergency and I cannot be reached. I acknowledge that Parkview Baptist Church has my permission to use my child’s photograph. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.