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Christ Lutheran Church Youth Registration
Please complete a form for each child aged 2 years old to 5th grade.
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* Indicates required question
Child's Name (and any preferred nickname)
*
Your answer
Child's Address (Please include city, state, and zip code.)
*
Your answer
Child's Birthdate
*
MM
/
DD
/
YYYY
Child's Current Age
*
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Child's Current Grade
*
not in school
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
Name, phone number, and email address of Contact #1 (who is allowed to pick up child)
*
Your answer
Name, phone number, and email address of Contact #2 (who is allowed to pick up child)
*
Your answer
(optional) Name, phone number, and email address of Contact #3 (who is allowed to pick up child)
Your answer
Allergies or other Medical Conditions
*
Your answer
Does your child carry an Epi-Pen?
*
Yes
No
(optional) Is there anything else you would like us to know about your child?
Your answer
If you are not available, and a medical emergency arises, may the supervising adult seek help from the nearest hospital?
*
Your answer
Does Christ Lutheran Church have permission to use pictures of your child for use in church publications (website, newsletter, etc.)?
*
Yes
No
Does Christ Lutheran Church have permission to use pictures of your child for use on the church's Facebook page?
*
Yes
No
Please put your name and the date below. This will serve as your signature.
*
Your answer
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