IGNITE Student Ministries Enrollment Form 2020

Fill in as much information as possible, if not known please leave blank. There will be space at the bottom for any additional information.

Students Name
Students Name
Mailing Address
Mailing Address
Home Phone
Home Phone
Parents Cell
Parents Cell
Text?
PLEASE INDICATE WHETHER OR NOT WE CAN SEND TEXT MESSAGES TO THE PARENTS CELL PHONES.
Parents Work Phone
Parents Work Phone
Parents/Guardian's Name
Parents/Guardian's Name
Address 2
Address 2
IF DIFFERENT, OR A 2ND ADDRESS WHERE THE CHILD ALSO LIVES
Address 2 Home Phone
Address 2 Home Phone
Emergency Contact
Emergency Contact
OTHER THAN A PARENT
HOME PHONE
CELL PHONE
WORK PHONE
GROUP POLICY NUMBER
INSURED'S NAME
PRIMARY PHYSICIAN
PHYSICIANS ADDRESS
DENTIST
DENTISTS ADDRESS
PLEASE PUT ANY OTHER INFORMATION THAT THERE MIGHT NOT BE SPACE FOR HERE.
Medical & Media Release
In the event of an emergency, sponsors/leaders of NERC (New Era Reformed Church) will first try to contact the parent/legal guardian, second the emergency contact listed. If no one can be reached and to assure the health and safety of the child, I hereby authorize and appoint as my attorney-in-fact, NERC and its sponsors/leaders to arrange for medical and dental care, and to give oral or written consent in my absence for medical and dental treatment including surgery deemed necessary by a licensed physician. By clicking the box I indicate my willingness to take full medical insurance responsibilities for my son/daughter and to release NERC and its sponsors/leaders from any and all liability.
In permitting the member to participate, I am specifically granting permission to NERC to use the likeness, voice and words of the member in television, radio, films, newspaper, magazines and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purpose and activities of NERC and appealing for funds to support such activities.
Parents Signature:
Whats Next?
NERC will require your signature (pen on paper) on the release form. The church office will print these out and they will be available for signature any time the church office is open, or special arrangements can be made if you contact the church office. You can also (BEFORE YOU PRESS SUBMIT) print the form on this page and sign it and submit it as is. If you have any questions or difficulties please contact the church office. 231-861-2501.