CLV Youth Registration

Please complete this form prior to participating in our Middle School and High School program. If you have questions, let us know. We are happy to answer them! Email questions to (Middle School) Terry Marcus terry@christlutheranvail.org or (High School) Stacy Lowe foghorn97@msn.com.

YOUTH INFORMATION

Youth Name *

First Name Last Name

Youth Email (or Parent) *

example@example.com

Youth Cell Phone *

Please enter a valid phone number.

Birth Date *

Month Day Year

Grade (as a whole number - 6, 7, etc) *

School Attending *

Gender *

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1

Name *

First Name Last Name

Cell Number *

E-mail *

example@example.com

Parent/Guardian 2 (Encouraged but not required :)

Name

First Name Last Name

Cell Number

E-mail

example@example.com

EMERGENCY INFORMATION

Emergency Contact's Name (other than parent/guardian) *

First Name Last Name

Relationship

Phone Number *

Alt. Phone Number

Medical Insurance Company *

Insurance Policy Number *

HEALTH INFORMATION

Please list all current medications (Prescription or Over-the-counter)

Please list all allergies (food, environmental or drug)

Please list any medical or physical limitations

Any other information you would like us to know

CONSENT FOR CARE & LIABILITY WAIVER

Consent for Emergency Care

In case of an emergency, I understand every effort will be made to contact me or the emergency contact listed. If I or my contact cannot be reached, I hereby give my permission to the licensed health care practitioner selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication.

I agree to the Consent for Emergency Care. *

Yes

Liability Waiver

I and my family hereby waive, release and discharge any and all rights and claims for damages I/we may have against Christ Lutheran Vail Church, church staff and adult volunteers arising out of or from any illness, accident or other occurrence causing injury to any person or property during youth trips or events.

I agree to the Liability Waiver. *

Yes

CONFIRMATION

BY CHECKING 'YES' TO THE 'I AGREE' BOX AND ENTERING MY FULL NAME I RECOGNIZE I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AND WILL BE AS EQUALLY BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

I Agree: *

Yes No

Name *

First Name Last Name

Date *

Date

Youth Group Registration