Shepherd Summer 2019 Registrations
Children, Youth, and Family Events at Shepherd of the Hills - Shoreview, MN
Parent(s)/Guardian(s) Names: *
Your answer
Address, City, State, Zip: *
Your answer
Parent Home or Cell Phone *
Your answer
Parent Cell Phone
Your answer
Household Email Address *
Your answer
Emergency Contact - Other than Parent/Guardian. Noting Relationship and Phone Number *
Your answer
My Family Is Registering to Attend Family Camp *
Youth/Child's Name *
Your answer
Date of Birth *
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Grade Fall of 2019 *
Your answer
Registering for (Check All that Apply): *
Required
Youth/Child's Name
Your answer
Date of Birth
MM
/
DD
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YYYY
Grade Fall of 2019
Your answer
Registering for (Check All that Apply):
Youth/Child's Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Grade Fall of 2019
Your answer
Registering for (Check All that Apply):
Youth/Child's Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Grade Fall of 2019
Your answer
Registering for (Check All that Apply):
Youth/Child's Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Grade Fall of 2019
Your answer
Registering for (Check All that Apply):
Please list any physical or mental health conditions, limitations, restrictions or allergies your child(ren) has:
Your answer
Physician's name: *
Your answer
HMO/Clinic Name: *
Your answer
Preferred Hospital: *
Your answer
Medical Insurer & Policy #: *
Your answer
Medical Information/Release: All events and programming are volunteer led with a staff person present. In the event of an illness, my above named child(ren), I hereby offer consent to any adult chaperone of a Shepherd of the Hills Lutheran Church Event to seek medical assistance on his/her behalf. My child(ren) has permission to ride in the vehicle of the staff or chaperone. In addition, I hereby agree to release, hold harmless and indemnify Shepherd of the Hills Lutheran Church and its staff, officers and chaperones from any and all liability either for any claims or causes of action which might result from this or any subsequent child/youth activity or trip. I hereby give my consent for emergency medical care in my absence. Care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my child. A photocopy of this authorization shall be as valid as the original. I give permission for Shepherd of the Hills to use, publish, or disclose in newsletter, brochures, posters, website or other media-related vehicles, any photographs, videos, audios, or other material in which my child may have appeared, spoken or written or otherwise been represented. No names shall be attached to any media used. Your Name here will be recognized as your signature: *
Your answer
Date of Signing: *
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To pay for your registration online go to this website listed below making note of what the payment is for or bring a check into the main office:
Submit
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