Youth Annual Registration, Medical Consent & Permission Form

Youth Annual Registration, Medical Consent & Permission Form
By completing this annual registration form, you give permission for your child to participate in all youth activities at Christ the Savior Lutheran Church from July 2022 - August 2023. In addition to registration, reservations may be required for specific events.

You may update your information at anytime throughout the year using this form.
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*
School attending*
Student Cell Phone*

Area CodePhone Number
Would you like to receive text reminders? *
Student email*
example@example.com
T-shirt size *
Has student been baptized?*
Home Phone Number*

Area CodePhone Number
Family email*
example@example.com
Father's Name

First NameLast Name
Mother's Name

First NameLast Name
Father's Cell Phone

Area CodePhone Number
Would you like to receive text reminders? *
Mother's Cell Phone

Area CodePhone Number
Would you like to receive text reminders? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Relationship to Student
Insurance Information
Insurance Company*
Policy/Group Number*
Name of Insured*
Relationship to Student*
Doctor's Name*
Doctor's Phone Number*

Area CodePhone Number
Hospital Preference
Special Health Information
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof.
Should this child's activities be restricted for any reason?*
Allergies to: (please check all that apply)*

PollensMedicationsFoodInsect BitesNone
List specific allergies:
Regular Medications taken:*
When and how often will medication need to be given:
Dietary Restrictions*
If the need should arise while at an event, my child may receive age/wt appropriate dose of: (please check all that apply)*

Acetaminophen (i.e. Tylenol)Cough DropsIbuprofen (i.e. Motrin)Tums
Medical, General Release and Hold Harmless and Media Release Agreement
As the parent or guardian of student listed above, by signing electronically, I agree to the Child Medical Release Form as state above*

Clear
As the parent or guardian of student listed above, by signing electronically, I agree to the General Release and Hold Harmless as state above*

Clear
As the parent or guardian of student listed above, by signing electronically, I agree to the Media Release as state above*

Clear
Today's date:*

MonthDayYear
Date
Student Code of Conduct
I, the student, have read the above Student Code of Conduct, my Health Information, and permission to participate in youth group activities. I agree to abide by all stated personal limitations and code of conduct. *

Clear
Please verify that you are human*
Should be Empty:

Youth Annual Registration, Medical Consent & Permission Form

Insurance Information

Special Health Information

Medical, General Release and Hold Harmless and Media Release Agreement

Student Code of Conduct