Registration Form
The purpose of this release is to provide emergency information to medical personnel in the event of injury or
illness during a field trip or activity. To be valid this form must be signed by a parent/guardian and returned to
Return to First Presbyterian Church, 520 Royal Palm Blvd., Vero Beach, FL 32960
I am registering my child for ____________________________________________
event
on __________.
date
I give permission for my child to go on this field trip or attend this event. In the event of injury or illness, I authorize
First Presbyterian staff to obtain treatment from the closest emergency medical facility. In addition, I do hereby
consent to any and all emergency medical treatments that may be deemed advisable or necessary by a qualified
medical doctor.
_____________________________________________________________________
Signature Parent/Guardian Date
_____________________________________________________________________
Child’s Name
______________________________________________________________________
Address
______________________________________________________________________
Date of last tetanus or DPT Known allergies
_______________________________________________________________________
Prescription medication taken on a regular basis Other medical condition or needs
_______________________________________________________________________
Child's physician and telephone number
_______________________________________________________________________
Insurance Carrier Policy # Subscriber Name
_______________________________________________________________________
Parent/Guardian Name Daytime Phone Cell Phone
_______________________________________________________________________
Emergency Contact Name & Telephone
Reservations are confirmed at time of payment.
................................................................................................................................................
Office use: date received _________________ amount ________ Check# ___________