Wellspring Students - Winter Fresh Registration & Health Form
We're thrilled your student will be joining us for this powerful, Christ-centered weekend! In order to register your student, please fill this out for each student in your family that will be in attendance. If you have more than one student in your family attending, there will be a link after submission that will initiate a new form for you.
Your email
*
example@example.com
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Participant Information
Name
*
First Name
Last Name
Gender
*
Male
Female
DOB
*
-
Month
-
Day
Year
Age
*
Grade
*
6th
7th
8th
9th
10th
11th
12th
Adult Sponsor
T-Shirt Size
*
Please Select
S
M
L
XL
2XL
3XL
Adult sizes only.
Please list any medically necessary dietary restrictions:
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Cell #
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Parent/Guardian Info
Parent/Guardian 1: Name
*
First Name
Last Name
Parent/Guardian 1: Relation to student
*
Parent/Guardian 1: Cell #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1: Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Add Parent/Guardian 2
Parent/Guardian 2: Name
First Name
Last Name
Parent/Guardian 2: Relation to student
Parent/Guardian 2: Cell #
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2: Address (if different from Parent/Guardian 1)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Student Medical Info
Please list any health or medical information about the participant that we should know about.
Please list any known allergies (including food and medication allergies).
The following is a list of over-the-counter medications. Please select any item you DO NOT WANT USED to care for your child.
Tylenol (acetaminophen)
Motrin (Ibuprofen)
Aleve (naproxen sodium)
Loperamide
Colace
Lidocaine
Robitussin
Betadine for wound care
Neosporin for wound care
Hydrogen peroxide for wound care
Hydrocortisone ointment
Throat lozenge
Zicam
Pepto-Bismol
Tums
MiraLAX
Claritin
Benadryl
Electrolyte drink
Camphphenique
Other
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Prescription Medication Authorization
I hereby request that the below-listed medication(s) be given to my child.
Rows
Medication
Dosage
Frequency
Reason for taking
1
2
3
4
5
Parent/Guardian signature
Submit
Should be Empty: