Oasis 2007 and 2008

YOUTH Registration Form
IMPORTANT! Please read: Fill out completely and legibly and bring with you to Oasis.
You must have this form completed in order to participate in all scheduled events and activities!
First Name:_______________ Middle In.:______ Last Name:________________________________
Address:______________________________ City:___________________ST:____ Zip:__________
Phone: (

)_________________ Email: _______________________________________________

Date of Birth: ____/____/____

Male:____ Female:____

High School:___________________________________ Grade in High School: 9 10 11 12
Church with whom you’ll be attending Oasis:_____________________________________________
Church City:______________________ Church St:_____ Youth Min./Sponsor:__________________
Home Church (if different from above):__________________________________________________
Church City:______________________ Church St:_____ Youth Min./Sponsor:__________________
In Case of an emergency we should contact:
Name: _______________________________ Relationship to Youth: _________________________
Phone Number/s: __________________________________________________________________
Home

Work

Cell

Family Doctor Name and Number: _____________________________________________________
Are there any activities your child should not participate in?

Yes

No

If YES, please list: _________________________________________________________________
Please list any medications your child is currently taking:____________________________________
________________________________________________________________________________
Please list any allergies and reactions your child has:______________________________________
________________________________________________________________________________
Health Ins. Co: _________________________________ Policy #:____________________________
Medical Release and Liability Waiver
IN CASE OF EMERGENCY: I hereby give permission to Roanoke Bible College, by it’s representatives, Steve Jackson, Julie
Fields or Lisa Pipkin, or by my child’s youth minister/sponsor (named above) to hospitalize, secure treatment for and to order
anesthesia or surgery for my child named above. I further agree to be responsible for any and all bills incurred for such treatment.
I hereby give full authority to the above mentioned representative of Roanoke Bible College to use their discretion in determining if
such medical treatment is necessary, and I release Roanoke Bible College from any responsibility of the results of that
determination. I also agree to indemnify and hold harmless Roanoke Bible College and their employees, officers, agents, and/or
affiliates in the event of any damage, either to person or property, sustained by my child. I further release Roanoke Bible College
from any responsibility other than normal supervision and care of my child.

Parent/Guardian (print):______________________________________________________________
Signature:_______________________________________ Date:____________________________

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