2025 Winter Rally Registration/Medical Release Form

Queens Section Royal Rangers

2025 Winter Rally Registration/Medical Release Form
This form must be completed in its entirety, including the signature of a parent/legal guardian.
Without a complete form, boys will not be allowed to participate.
All event attendees (boys, leaders, & guests) must complete and submit a form.
If a field does not apply to you, please use “Not applicable” or “N/A.”
Incomplete forms will not be accepted through the portal.
Name*
Outpost*
Age Group*
Date of Birth*
Address*

Address

Street Address Line 2

CityState

Zip
Emergency Contact #1*
Full Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Emergency Contact #2*
Full Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Any known allergies, illness, injuries, or disabilities*
If you don't have any please enter in "N/A"
Current Medications*
If you don't have any please enter in "N/A"
Date of last Tetanus Booster*

MonthDayYear
Date
Physician Name*
Phone Number*
Format: (000) 000-0000.
Insurance Company*
Phone Number*
Format: (000) 000-0000.
Policy Holder's Name*
Policy Number*
PARENTAL/GUARDIAN RELEASE
I, hereby, give permission, for any and all medical attention to be administered to my child, in the event of accident, injury, sickness, etc, under the direction of the person(s) listed, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment.

This release is effective for the Queens Section Royal Rangers Winter Rally, March 1, 2025.

I will not hold the Queens Sectional Royal Rangers, Spanish Eastern District, or Elohim Christian Church liable
for any accident that may occur.
Name of Parent/Guardian*
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date when you are signing this form.
In case I cannot be reached. any of the following persons is designated to act on my behalf. (Add down below)
*Royal Ranger Leader:*
(Must be of 18 years or older and attending the event)
YesNo
YesNo

Winter Rally Registration Fee*

Winter Rally Registration

This is your registration fee for the 2025 Royal Rangers Winter Rally. This is required to participate in the event.

$15.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Queens Section Royal Rangers

PARENTAL/GUARDIAN RELEASE

In case I cannot be reached. any of the following persons is designated to act on my behalf. (Add down below)

Payment Methods