What is your relation to the child(ren)
Please include your relationship
Please include your relationship

---

Emergency Contact Information

In case of an emergency, and we can’t reach the parent or guardian, please contact:

Contacts Name
Please add your the Emergency Contacts First and Last name
Please add your Emergency Contact's First and Last name

Contacts Phone Number
Please enter an emergency contact phone number.
Not a valid phone number

Do you give World Harvest Church and its associated programs/staff members to secure emergency transportation for your child(ren) in the event of an illness or injury which requires emergency treatment?

The Emergency Transportation service will determine the facility to which your child(ren) will be transported. I DO give permission I DO NOT give permission

---

Student Information

Student's First Name
Please add your childs First and Last name
Please add your childs First and Last name

Student's Last Name
Please add your childs First and Last name
Please add your childs First and Last name

Student's Gender Male Female

Student's Age

Going into Grade
Please add the grade your child is going into next year
Please add the grade your child is going into next year

School Your Child Attends
Please add the name of your childs School
Please add the name of your childs school

Do you attend WHC? Yes No

If no, what church do you attend?

MEDICAL INFORMATION
(PLEASE FILL-OUT COMPLETELY)

Please check any that apply to your child:

Allergies	Heart Condition
Emotional Disability	Hyperactivity
Seizures	Physical Limitation
Asthma	Learning Disability
Hemophilia	Other

If any of the medical conditions listed apply, or any other medical condition please explain:


Food Allergies:


Please list ALL allergies here:


Please list any additional information about your child that would be useful for our staff to know:


I want to register a second child:
I want to register a third child:
I want to register a fourth child:
I want to register a fifth child:

Type your name for your electronic signature, including your middle inital:
Please add your signature, including your middle inital
Please add your signature, including your middle inital.

By submitting this form I am affixing my electronic signature, which is legally equivalent to my handwritten signature.