Event Registration Form

United Lutheran Church General Event Registration Form

GENERAL INFORMATION

Youth First & Last Name:_______________________________________

Grade: _____ (During 2009-10 School Year) School: ___________________

Birthdate: Month _______ Day____ 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 (Please Print):____________________________

Signature:___________________________________ Date: __________

Insurance Company_________________________________________

Member # ____________________________

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

___________________________________________________________

*You will need to PRINT this form and turn it in completed by the registration deadline. (Or... sign up on the sheet provided on the YOUTH TABLE in the church hallway.)