First Lutheran Church Youth Registration Form 2020-2021
CHILD´S INFORMATION
CHILD'S FIRST NAME *
CHILD'S LAST NAME *
Goes by
Age *
Birthdate (MM / DD / YYYY) *
Grade *
School *
Baptismal Birthdate (not required)
Primary Phone *
Address *
City / Zip Code *
PARENT-GUARDIAN´S INFORMATION
1st Parent/Guardian Name *
1st Parent/Guardian Cell Number *
1st Parent/Guardian Email *
2nd Parent/Guardian Name
2nd Parent/Guardian Cell Number
2nd Parent/Guardian Email
MIDDLE & HIGH SCHOOLERS ONLY (next 2 questions)
Youth´s Cell Number
Youth´s Email
HEALTH INFORMATION
Allergies, Reactions, Asthma, Diabetes, Other?
Adaptive equipment, glasses, contacts, hearing aids, etc.?
Other helpful health-related information?
If your child will be taking any medication while at a FLC program, be sure staff are informed.
IN CASE OF EMERGENCY -- MUST list two people other than parent/guardian listed above!
Name #1 *
Relationship #1 *
Phone number #1 *
Name #2 *
Relationship #2 *
Phone number #2 *
PERMISSION
Permission
ELECTRONIC SIGNATURE
By clicking the "I accept" box below, you are signing this youth registration electronically. You agree your electronic signature is the legal equivalent of your manual signature on this registration.
Your name *
TODAY'S DATE (MM / DD / YYYY) *
Thank you for taking the time to complete this youth registration form! We look forward to an exciting year of ministry with your child!
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