GEMS Program at Streams | Grand Rapids, MIStreams

Full Name of Person Completing this Form*

Relationship to Student*

Student's Full Name*

Student's Date of Birth*

Gender*

Race/Ethnicity*

Primary Language*

Student's Grade*

School*

Parent / Guardian's Full Name*

Parent / Guardian Email*

Parent/Guardian Marital Status

Student's Home Address*

Street Address City State ZIP Code

Parent / Guardian Phone*

Is this a home or cell phone?*

Emergency Contact's Full Name*

Emergency Contact Phone*

Does your student have any allergies or medical conditions?*

If yes, please explain:

If you are the child's parent/guardian, please submit your consent below. If not, leave blank.*

*I understand that while participating at Streams of Hope that my child is expected to conduct himself/herself in an orderly manner. They are expected to respect the instructor and other students.

*I understand that if my child’s behavior/attitude is disruptive, they will risk removal from the program.

*I am the legal parent/guardian of this student and do hereby consent and allow Streams of Hope, Grand Rapids, MI to handle any type of medical care for my child including but not limited to the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is in the care of Streams of Hope and I am not reasonably available by telephone to give consent.

*I also hereby grant permission to Streams of Hope and its representatives to take photographs or videos of me, and/or my child while at Streams of Hope located at 280 60th St SE, Grand Rapids, MI 49548. I further grant producers and their representatives the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of these images and recordings in any media now known or later developed. I acknowledge that Streams of Hope owns all rights to the images and recordings.

*I hereby waive any right to inspect or approve the use of the images or recordings or of any written copy. I also waive any right to royalties, or other compensation arising from or related to the use of the images, recordings, or materials. I hereby release, defend, indemnify, and hold harmless the producers from and against any claims, damages, or liability arising from or related to the use of the images, recordings, or materials, including but not limited to claims or defamation, invasion of privacy, or rights of publicity or copyright infringement, or any misuse, distortion, blurring, alteration, optical illusion or use in composite form that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I consent.

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Date*

GEMS Registration

GEMS is taking a break for the summer and will return this fall.

Please submit an inquiry by completing the form below.

We strive to be the hub of a vibrant, growing, empowering community where neighbors are committed to the growth of each person while maintaining our uncompromised values and love for Jesus.