First Lutheran Church Youth Registration Form 2019-2020
CHILD´S INFORMATION
Child´s name *
Your answer
Goes by
Your answer
Age *
Your answer
Birthdate (MM / DD / YYYY) *
Your answer
Grade *
Your answer
School *
Your answer
Baptismal Birthdate (not required)
Your answer
Primary Phone *
Your answer
Address *
Your answer
City / Zip Code *
Your answer
PARENT-GUARDIAN´S INFORMATION
1st Parent/Guardian Name *
Your answer
1st Parent/Guardian Cell Number *
Your answer
1st Parent/Guardian Email *
Your answer
2nd Parent/Guardian Name
Your answer
2nd Parent/Guardian Cell Number
Your answer
2nd Parent/Guardian Email
Your answer
MIDDLE & HIGH SCHOOLERS ONLY (next 2 questions)
Youth´s Cell Number
Your answer
Youth´s Email
Your answer
HEALTH INFORMATION
Allergies, Reactions, Asthma, Diabetes, Other?
Your answer
Adaptive equipment, glasses, contacts, hearing aids, etc.?
Your answer
Other helpful health-related information?
Your answer
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 *
Your answer
Relationship #1 *
Your answer
Phone number #1 *
Your answer
Name #2 *
Your answer
Relationship #2 *
Your answer
Phone number #2 *
Your answer
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 *
Your answer
TODAY'S DATE (MM / DD / YYYY) *
Your answer
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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