CLV Youth Registration

Please complete this form prior to participating in our Middle School (5th - 8th grade) and High School (9th- 12th grade) 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

MS/HS Youth GroupConfirmation

Youth Name*

First NameLast Name

We are asking for your youth's email address and cell phone number for our database. It is used to communicate with your youth and to give them ownership in keeping up to date on youth events, functions and details. As a parent/guardian, you will also receive these communications. All the information collected on this form is kept confidential and is used only for Christ Lutheran Vail Youth Group purposes.

If your youth does not have an email address and/or cell phone number, please leave the field blank. Parent/guardian contact information is collected below.

Youth Email

example@example.com

Youth Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Birth Date*

MonthDayYear

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

School Attending*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are your favorite snack foods? (ie. rice krispies, chips, granola bars, broccoli, etc.)

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1

Name*

First NameLast Name

Cell Number*

Format: (000) 000-0000.

E-mail*

example@example.com

Parent/Guardian 2 (Encouraged but not required :)

Name

First NameLast Name

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

EMERGENCY INFORMATION

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

First NameLast Name

Relationship

Phone Number*

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

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

PHOTO/VIDEO RELEASE

I give Christ Lutheran Vail church permission to photograph, interview, or video tape my youth; and give permission to use my youth’s photograph on the CLV website, social media sites and in print materials.

I understand that photographs, interviews, and/or video tapes may be used for public viewing.

In giving my permission to use my youth’s photograph, I understand that NO YOUTH’S NAME OR OTHER IDENTIFYING INFORMATION WILL BE INCLUDED WITH HIS/HER PICTURE.

I agree to my youth's participation, without financial compensation, and I understand that this releases any claims against Christ Lutheran Vail Church, any CLV employees and its photographers from any future claims, as well as any liability arising from the use of said photograph/interview/video tapes or portions thereof used for public viewing.

I allow the reproduction and publication of my youth's imagesI do not allow the reproduction and publication of my youth's images

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.

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.

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.

YesNo

Name of Parent/Guardian*

First NameLast Name

Date*

Date

Youth Group Registration