Clone of Young Christians' Weekend Registration Form

Young Christians' Weekend Registration

Fill out your medical information carefully
Name of Person Attending

First NameLast Name
Phone Number of Person Attending (guardian #s should be entered under emergency contact)
Birth Date of Person Attending

MonthDayYear
Grade (if applicable)
Email
example@example.com
Address of Person Attending

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Medical History
Any food, medication or environmental allergies?

YesNo
Alergies? Check all that apply

FoodMedicationEnvironmental
Please list and explain any allergies
List any ongoing Medical Conditions (asthma, seizures, headaches):
Is any medication required?

YesNo
List any medication taken regularly:
I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure.
Medical insurance details
Name of Insurance Company:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number:
Expiry Date:

DayMonthYear
In Case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Home phone
Work phone
What is this person's relationship to the individual registered above?
Should be Empty:

Young Christians' Weekend Registration