Participant Form | CBF Virginia

Church Name

Event*

Please select the event for which you ar filling out this form.

I am filling this form out for*

Myself

Someone Else

Your Name*

First Last

Your Phone Number*

Relation to Participant*

Participant Information

Participant is a*

Student

Chaperone

Other

Participant Name*

First Last

Gender*

Date of Birth*

Age

Grade in School*

Participant Address

Street Address Address Line 2 City ZIP Code

Phone

Emergency Contact Information

Name*

First Last

Phone*

Relationship to Participant*

Optional Second Contact

Name

First Last

Phone

Relationship to Participant

Medical Information

Insurance Company*

Group Number*

Policy Number*

Physicians Name*

Physicians Phone*

Allergies*

Enter "none" if not applicable

Medications*

Enter "none" if not applicable

Authorization for Treatment & Release

Photo Release*

Photographs, audio recordings, and video recordings may be created during the event and I give permission to the Cooperative Baptist Fellowship of Virginia to use any or all recordings of me or my child in publications, videos, website design, or other media expressions. CBFVA will never release last names of minors in print or web publications.

Yes I give permission

No I do not give permission