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Youth Ministry Registration
Please complete one form per youth.
*
Required
Errors
Youth's First Name
*
Youth's Last Name
*
Gender
*
Male
Female
Grade, Fall 2011
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School
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Youth's Cell Phone
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Birthdate
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Contact #1 Name
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Contact #1 Street Address
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City
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Zip Code
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Contact #1 Primary Phone
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(
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-
ext.
Contact #1 Alternate Phone
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-
ext.
Contact #1 Primary E-Mail Address
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Contact #2 Name
*
Contact #2 Street Address
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City
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Zip Code
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Contact #2 Primary Phone
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(
)
-
ext.
Contact #2 Alternate Phone
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(
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-
ext.
Contact #2 E-Mail Address
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May we use a group photo with your youth in it on our website or in printed materials?
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Yes
No
________________________________________________________
MEDICAL INFORMATION
Do you have medical insurance?
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Yes
No
If yes, please complete insurance information fields
Insurance Company
Group/Policy Number
Please list all health related issues/physical limitations/medications and prescription drugs/drug allergies or medical precautions a medical team should be aware of.
*
_______________________________________________
PARENTAL CONSENT
I understand that every effort will be made to reach me in the event of an emergency. I give my permission for the personnel of Meredith Drive Reformed Church to secure emergency treatment as deemed necessary. I agree to assume financial responsibility for this treatment.
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Doctor's Name
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Doctor's Phone Number
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(
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ext.
Hospital Preference
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I give my permission for my youth to ride in any vehicle deisgnated by the adult in whose care my youth has been entrustesd while attending and participating in activities sponsored by Meredith Drive Reformed Church
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Your Name and Date
*
My name in the field above acts as my signature and verifies that I am the person who completed this form.
*
Additional Comments
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