Child/Youth Registration and Medical Information/Release
Christian Education Programs
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C/Y’s Name: _________________________________________________ Date of birth ___/___/___
School: _______________________________________ Grade or age: ____________ (Fall of 2004)
Parent(s)/Guardian(s) Name(s): __________________________, ____________________________
Address: _________________________________________ , ____________________, IN , __________
Home Phone: _____________ (F)Work Phone: _____________ (M)Work Phone: ________________
Cell Phone or Pager (whom): ________________ E-mail addresses: _________________________
Non-custodial Parent (if applicable): _____________________________________________________
Address: _____________________________________ , _______________________, IN , ______
Home Phone: _____________ Work Phone: _____________ E-mail address: ___________________
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Names, ages and grades of brothers and sisters: _______________________________________________
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Programs for which you wish to register this child/youth. [Check all that apply]
Childcare: Sunday School classes: ____ Infant (birth to 18 mos.) ____ Pre-K-K (ages 4-6) ____ Toddler I-II (18 mos. to 3 yrs) ____ Grades 1-2 ____ Pre-K (ages 4-5) ____ Grades 3-4-5 ____ Mom’s Morning Out ____ Grades 6-8 ____ Grades 9-12 Other Youth Programs: ____ Midweek Praise Session ____ Chi Rho (grades 6-8) ____ Epsilon Theta (grades 9-12) ____ Children’s Choir |
Is there anything special about your child that you would like us to know, (e.g., custodial arrangements, persons to whom your child should not be released?) ____________________________________________
MEDICAL INFORMATION/RELEASE
Child/youth full name: ____________________________________________
Birth date: ____/______/_____
Allergies: _____________________________________________________________________
(foods, medications, insect bites, etc.)
Prescriptions/reason: (e.g. Claritan/allergies; Ritalin/ADD). All prescription meds will be administered by an adult counselor.*
______________________________________________________________________________________
____ Over-the-counter medicines (e.g., Tylenol, Pepto-Bismol) may be administered to my C/Y for minor ailments.
Other health issues concerning my C/Y are: ____________________________________________________________
______________________________________________________________________________
C/Y’s Primary Physician: __________________________ Telephone No: _________________
Dental Insurance Carrier: ______________________ Policy No.:____________________
Other Important Health Care Professionals (e.g., eye doctor, orthodontist, psychotherapist, allergist, etc):
Emergency Contact/Relationship/Phone Numbers (please list at least one person not in your household: e.g. Joan Smith/neighbor/123-4567) ______________________________________________________________________________
IN CASE OF EMERGENCY, I HEREBY AUTHORIZE THE ADULT LEADER IN CHARGE TO SELECT AND SECURE APPROPIATE MEDICAL PERSONNEL FOR MY CHILD/YOUTH (C/Y). FURTHER, I AUTHORIZE THOSE MEDICAL PERSONNEL TO PERFORM AND PROVIDE ALL REASONABLY NECESSARY MEDICAL CARE INCLUDING, BUT NOT LIMITED TO, DIAGNOSTICS (E.G., RADIOLOGY); HOSPITALIZATION, ANESTHESIA, SURGERY AND PRESCRIPTION DRUGS, ADVISABLE FOR THE HEALTH OF MY CHILD/YOUTH.
______________________________________ ___________________________________
(Parent or Legal Guardian’s Signature) (Date)
*It is understood that certain health issues such as asthma or diabetes necessitate that a c/y be able to participate in his/her own
disease management. If so, please attach an explanatory rider to this document.