PowerZone Registration

Warren Community Fellowship

56523 Columbia River Hwy.

Warren OR        (503) 397-4387

July 7 –11

Please Print, Fill Out,  bring to Church
 

Household Information

Household Name: ________________________

Mother:  _________________________

Father: _________________________

Household Address: ___________________________

City: ________________________________________

Zip: _____________________

Home Phone: _________________________________

Cell Phone: ___________________________________

Email: ________________________________________

 

Student Information

1) Student Name: _____________________________

Age: ________ Grade Just Completed: __________

 Date Of Birth __________________

 Please list any medication being taken,

medical allergies, medical conditions, or

other pertinent information to the child’s

health.

_______________________________________________

_______________________________________________
 

 

Medical Release:

I (we) understand that, in the event medical treatment is
required, every effort will be made to contact me. However,
if I cannot be reached, I give my permission to the staff
of Warren Community Fellowship to secure the services
of a licensed physician to provide the care necessary,
including anesthesia, for my child’s well-being.
 

Signed ______________________________________

(Parent or legal guardian)
 

Date _______________
 

Emergency Contact Person ____________________
 

Emergency Phone Number ____________________