ELC Youth/Child Registration & Medical Permission Form 2017-2018
RequiredRequired Question(s)
Required
First and Last Name of Student
(First Child):
 

50 characters left.
First and Last Name of Student
(Second Child):
 

50 characters left.
First and Last Name of Student
(Third Child):
 

50 characters left.
Required
Grade entering Fall 2017:
(First Child)
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Grade entering Fall 2017:
(Second Child)
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Grade entering Fall 2017:
(Third Child)
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Required

Birthday:

(First Child)

 

50 characters left.

Birthday:

(Second Child)

 

50 characters left.

Birthday:

(Third Child)

 

50 characters left.
Required
Parent/Guardian Information:
(Please include all parents'/guardians' names, as well as your cell phone rather than your work phone number.)

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required

Name of people authorized to sign out the child or youth:

 

350 characters left.
Required

My child's picture may be used to promote the ministries of Edgebrook Lutheran Church in our communication via email to ELC and on social media platforms.

Yes
No
Required

Name, relationship, phone number of emergency contact person not listed above:

 

350 characters left.
Required

Please list ALL allergies (food, meds, pets, etc.), any special dietary needs, any medications that your child/youth is taking on a regular basis, and any additional health, emotional or other conditions of which we should be aware. 

If these do not apply to your child/youth, please type N/A. 

 

1000 characters left.
Required

Medical Information --

Medical Insurance Company:

 

50 characters left.
Required

Medical Information --

Medical Insurance Policy Number (& Group Number, if applicable):

 

50 characters left.
Required

Medical Information --

Name of Policy Holder:

 

50 characters left.
As parent/guardian of the above named minor, I hereby grant permission for my son/daughter to participate in events and activities through Edgebrook Lutheran Church for the 2017-2018 program (September 2017-September 2018).
I also grant permission for Edgebrook Lutheran Church staff, Sunday School teachers, or any other adult leader with our group to take whatever steps may be necessary to obtain emergency care as warranted for the well-being of my son/daughter. These steps may include, but are not limited to, the following:
- Attempts to contact a parent or guardian
- Attempts to contact student's physician
- Seek medical examination/treatment for injuries/condition by a medical professional
 
Required
My electronic signature below indicates that I understand and agree to the policy and terms listed above, and agree that any expenses incurred in necessary emergency of other medical treatment will be borne solely by the student's medical coverage and/or family. I will not hold any leader or organization liable for any injury or accident.

Parent/Guardian Signature:
 

50 characters left.
Thank you for registering for Sunday School!
We look forward to seeing you at Rally Day on September 10th at 10am. Sunday School classes begin September 17th at 9:45am.
Have a blessed day!