This section is about the child or student who is participating at or with Coastal Community Church.:
*What grade will your student be in the Fall of 2021?:
*Primary Church Campus:
The following fields relate to the Parent or Legal Guardian (who will be the emergency Contact unless otherwise noted):
If you would like to have someone other than the Parents or Legal Guardians as the Emergency Contact please list them below.:
Emergency Contact Relationship:
In the event we cannot reach the Emergency Contact who can we call?:
*Relation to family:
Please provide information about insurance and any medical issues we should be aware of.:
*Do you carry family medical/hospital insurance?:
Please provide information regarding any of these health issues. | Asthma | Emotional Disorder | Physical Handicap | Bleeding/Clotting Disorder | Nervous Disorder | Hay Fever | Drug/Allergies | Epilepsy | Insect Stings Diabetes | Seiz:
Health Issues - Specific Detail:
List Any Activity Restrictions:
List surgeries or serious injuries and dates:
Chronic illness, medical conditions or allergies:
Current medication (send with instruction):
By typing my first and last name in this box I am signifying that I am the parent or guardian for the child listed above and have the authority to enter into this agreement on their behalf.:
If you are a Coastal Member please use the promo code- Member -for $25 off registration.
If you are registering more than one child, please use the promo code- Sibling -to get $25 off each sibling.
Please only use one promo code per child.