Parents

First Name

Last Name

First Name

Last Name

Mom's Phone Number

(###)

###

####

Dad's Phone Number

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student 1

First Name

Last Name

Birthdate

MM

DD

YYYY

Student 2

First Name

Last Name

Birthdate

MM

DD

YYYY

Student 3

First Name

Last Name

Birthdate

MM

DD

YYYY

Student 4

First Name

Last Name

Birthdate

MM

DD

YYYY

Student 5

First Name

Last Name

Birthdate

MM

DD

YYYY

Emergency Contact *

In case parent(s) cannot be reached, please list an emergency contact.

First Name

Last Name

Phone Number *

(###)

###

####

Photo Release

Student images are sometimes used on our social media pages, website, or family communications.  Names of students will never be released without further permission. I grant permission to PEAK Christian Academy to take and use: photographs and/or digital images of the child(ren) named above for use in social media, news releases and/or promotional materials. These materials might include printed or electronic publications, web sites, or other electronic communications. I authorize the use of these images without compensation to me.

YES

NO

Medical Consent *

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for PEAK teachers to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize PEAK staff to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution. I agree to assume financial responsibility for all expenses of such care.

I agree

Primary Physician

First Name

Last Name

Phone Number

(###)

###

####

Liability Release *

In consideration for the privilege of allowing my child(ren) to participate in PEAK, I agree to release and hold harmless Westminster Presbytarian Church as well as PEAK Christian Academy and its officers from any liability to or responsibility for bodily injury, damage or illness to the above-identified child(ren) while participating in any educational or athletic activity which may be directly or indirectly sponsored by PEAK.

I agree