Event Registration Form

United Lutheran Church General Event Registration Form

GENERAL INFORMATION (Please Print)

Event _______________________________________ Date___________

Youth First & Last Name:_______________________________________

Birthdate: Month _______ Day____ Year _______ Grade: _____
(During 2011-12 School Year)
Home Address:_______________________________________________

City: ____________________________________ Zip code: __________

Home Phone:____________ Youth Cell # (if applicable): ____________

Mom's Name: _______________Cell # __________Work # _________

Dad's Name: ________________Cell # __________Work # __________

Emergency Contact Person: ___________________________________
Relationship to Youth: _________________ Phone: ____________

Medical Authorization
I authorize treatment for the above minor should the event leaders feel it is necessary. I accept financial responsibility for any services performed.

Parent/ Guardian Name(s):___________________________________
Signature:__________________________________ Date: _________

Insurance Company_________________________________________

Member # ____________________________

Other Special Instructions (Allergies, Medications, etc.) ____________
___________________________________________________________

*Please PRINT and complete this form and turn it in to the youth director by the event registration deadline posted, OR sign up for the event directly at the Youth Table in the church hallway. Youth must also turn in an updated Youth Activity Permission Slip & Covenant once each school year.