Oak Harbor Assembly of God

Missionettes Online Registration Form

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Student's name


First Name	Last Name

Student's address


Address

Address Line 2

City	State	Zip Code

Student's date of birth

Click in box to select date

Which club is the student registering for?

Select all that apply

Rainbows - boys and girls ages 3-4 (must be toilet-trained)
Daisies - girls in Kindergarten
Prims- girls in 1st through 2nd grade
Stars- girls in 3rd through 5th grade
Friends- girls in 6th through 12th grade

Parent e-mail (not required if phone contact is preferred)

Email Address

Parent home or cell phone (not required if email contact is preferred)

Phone Number

Parents' name(s)

School student currently attends

Select from list

Does the student have any special needs or limitations we should be aware of including known drug allergies or medical problems?

Has the student asked Jesus into his/her heart?

Select one

Yes
No
I don't know

Has the student been baptized in water?

Select one

Yes
No
I don't know

Has the student been baptized in the Holy Spirit?

Select one

Yes
No
I don't know

Emergency Medical Release

I/we, the undersigned parents hereby authorize the adult leader(s) in charge as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care deemed advisable by and rendered under the general or special supervision of any physician and/or surgeon licensed under the Medical Practice Act on the medical staff of any accredited hospital, whether such diagnosis is rendered at the office or said physician or at said hospital. It is understood this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable. It is understood and agreed that this authorization will remain in effect for one (1) year from the date of signature unless cancelled in writing by the undersigned.

Date

Click in box to select date

Emergency Medical Release authorized by


First Name	Last Name

Emergency contact name


First Name	Last Name

Emergency contact phone

Phone Number

* required