GEMS Registration - First United Reformed Church

1) Download and fill out the Waiver, Consent, and Hold Harmless Form.

2) Scan and upload it to the registration form below or bring it to the first meeting your child(ren) attend.

3) Register below:

First URC GEMS Registration

Parent/Guardian First Names and Last Name: *
Home Address: *
Address 1
Address 2

City

State

Zip
Home Phone Number
Father's Cell Number
Mother's Cell Number
Other/Guardian's Phone Number
Home Email Address *
Family Physician *
Family Physician Address *
Address 1
Address 2

City

State

Zip
Family Physician Phone *
Medical Insurance Company *
Participant #1 Name: *
Participant #1 Date of Birth: *
Participant #1 Grade Entering: *
Participant #1 Insurance Policy Number *
Participant #1 Allergies to drugs or food:
Participant #1 List any and all special medications, pertinent information, or restrictions:
Participant #2 Name:
Participant #2 Date of Birth:
Participant #2 Grade Entering:
Participant #2 Insurance Policy Number:
Participant #2 Allergies to drugs or food:
Participant #2 List any and all special medications, pertinent information, or restrictions:
Participant #3 Name:
Participant #3 Date of Birth:
Participant #3 Grade Entering:
Participant #3 Insurance Policy Number:
Participant #3 Allergies to drugs or food:
Participant #3 List any and all special medications, pertinent information, or restrictions:
Participant #4 Name:
Participant #4 Date of Birth:
Participant #4 Grade Entering:
Participant #4 Insurance Policy Number:
Participant #4 Allergies to drugs or food:
Participant #4 List any and all special medications, pertinent information, or restrictions:
Participant #5 Name
Participant #5 Date of Birth
Participant #5 Grade Entering:
Participant #5 Insurance Policy Number:
Participant #5 Allergies to drugs or food:
Participant #5 List any and all special medications, pertinent information, or restrictions:
Emergency Contact Name: *
Emergency Contact Relationship: *
Emergency Contact Phone Number: *
Your Home Church:
How did you hear about GEMS? * (1 required)
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Upload Waiver, Consent, and Hold Harmless Form

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