Kids@Mountainview Registration Form

Child 1 *
Child 1
Birthday - C1 *
Birthday - C1
I, the parent or legal guardian of child listed above, a minor, by submitting this health card number, hereby authorize and give permission to the physician or medical practitioner, selected by Mountainview Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.
Special medications and/or pertinent information: (i.e. learning challenges, disabilities)
Child 2
Child 2
Birthday - C2
Birthday - C2
I, the parent or legal guardian of child listed above, a minor, by submitting this health card number, hereby authorize and give permission to the physician or medical practitioner, selected by Mountainview Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.
Special medications and/or pertinent information: (i.e. learning challenges, disabilities)
Child 3
Child 3
Birthday - C3
Birthday - C3
I, the parent or legal guardian of child listed above, a minor, by submitting this health card number, hereby authorize and give permission to the physician or medical practitioner, selected by Mountainview Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.
Special medications and/or pertinent information: (i.e. learning challenges, disabilities)
Child 4
Child 4
Birthday - C4
Birthday - C4
I, the parent or legal guardian of child listed above, a minor, by submitting this health card number, hereby authorize and give permission to the physician or medical practitioner, selected by Mountainview Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.
Special medications and/or pertinent information: (i.e. learning challenges, disabilities)
Family Address
Family Address
Family Phone #
Family Phone #
Name & Phone Number and relation to child?
I agree that photographs and/or videos may be taken of my child at Mountainview Christian Reformed Church programs and events, and may be used in the promotion of Mountainview Church. They may be published or used for any application in newspapers, videos, posters, slide presentations, FaceBook, YouTube, other social media and networking sites or otherwise displayed to the public—either in whole or in part by Mountainview Church.