Woodmen Valley Chapel

* First Student's Full Name
* Birthday
* Gender	select one Male Female
Allergies/Medical Conditions
Grade - Fall 2008	select one 6th 7th 8th 9th 10th 11th 12th
Second Student's Full Name
Birthday
Gender	select one Male Female
Allergies/Medical Conditions
Grade - Fall 2008	select one 6th 7th 8th 9th 10th 11th 12th
* Guardian's/Parent's Name
Child's Primary Address is with	select one Father Mother both parents
Address Line 1
City
State
ZipCode
E-Mail Address
Home and Cell Phone
Medical Release - I agree with the terms and conditions set below	NO YES
Parent Signature-Signing this form will allow your child to have immediate medical attention at any Medical facility. Please STOP BY YOUR STUDENT'S CLASS OR BY THE OFFICES TO SIGN THIS. THANK YOU!

MEDICAL RELEASE: In the event of an emergency, I understand that a reasonable effort will be made to contact me. If I cannot be reached, I hereby authorize an agent of Woodmen Valley Chapel to act on my behalf to seek emergency medical treatment for my child in the event that such treatment is deemed necessary by that agent. I authorize the physician selected by said agent to administer such emergency treatment as said physician deems necessary (in his/her judgment) under the circumstances. I understand and agree that I will be responsible for payment of said physician's fee and any and all other fees or expenses associated with such treatment. I hereby release Woodmen Valley Chapel, its agents and employees from any and all claims and liabilities resulting from adherence with these instructions.