Flawless Consent to Participate and Consent to Treat Registration Form-Minor
Location of Activity: Cross America 840 Daniel Drive Kokomo, IN 46901
Date of Activity: Saturday,  November 8, 2025 8:45am - 5:00pm (arrive at 830am)
**Girls may attend only ONCE as a GUEST. If desiring to serve after having gone through Flawless, please email us at: flawless.loved@gmail.com
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Guest Last Name *
Guest First Name *
Guest AGE - on event date (must be 11years old on date of event) Please note: There is ALOT of sitting and listening during the event. If you feel your daughter may have a hard time sitting still to listen, she may benefit from coming at an age older than 11, as the event could benefit her more then. *
Current Grade Level in School  *
School Attending  *
Church Affiliation? Please Type 'No' if not.
Best  Phone (Guest) *
Best  Email (Guest) *
 Birthday (Guest)  *
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 Home Mailing Address (Guest) *
City *
State *
Zip *
Guardian Last Name *
Guardian First Name *
Guardian Street Address *
Guardian City *
Guardian State *
Guardian Zip *
Guardian Best Phone Number (may receive texts/emails to update on event) *
Guardian Best Email for updates on event *
Guardian confirm Email
Emergency Contact Name (Day of Event) *
Emergency Contact Phone &  Alternate Phone *
Food or Drug Allergies? *
T-Shirt Size for Guest (Adult, preshrunk) *
Is your child currently under any form of medical treatment? *
If Yes, what are they being treated for? *
Known medical concerns or disabilities that may affect their participation in activities: (If so, please list) *
Medications we can administer if needed: *
Required
The following information is confidential and will only be used in case of emergency.
Consent to Treat: While my child is attending Flawless, I hereby authorize the adult(s) in charge or in his/her absence or disability, any adult accompanying or assisting him/her, to consent to the following medical treatment for the above minor: provide for, approve, and authorize any healthcare at any hospital, emergency room, doctor's office or other institution; employees and physicians, nurses, or other persons whose services may be needed for such healthcare; review and, if necessary, disclose the contents of any confidential medical records; and execute consent form required by medical or other health authorities incident to the provision of medical or surgical care to the child.         (Electronic Signature of Parent/Legal Guardian:) *
Insurance Holder
Insurance Company
Insurance Group/ID#
Today's Date: *
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