Northbrook Youth Programs Registration 2023-24
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Child's Last Name

Child's First Name
Parent/Guardian Name
Street Address, City, State, Zip
Phone Number
Email
If one parent does not live with the youth or child please fill out the following information if we are to contact that parent also.
Parent/Guardian Name
Street Address, City, State, Zip
Phone number
Email
Child's birthday
MM
/
DD
/
YYYY
Grade for This School Year
Special medical concerns, allergies, current prescriptions (including instructions for taking any prescriptions if given at Northbrook):
Is this child covered by medical insurance?
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Carrier's Name
Relationship to child
PERMISSION TO USE PICTURES THAT MAY INCLUDE YOUR CHILD
During LOGOS and youth programs we will be taking photographs and digital pictures of various activities involving our youth which may include your child. Please check the boxes below those uses of those photos which you approve.  
PARENT PERMISSION, MEDICAL RELEASE AND LIABILITY RELEASE FOR NORTHBROOK PRESBYTERIAN CHURCH

I understand that from September 2023 to August 2024, there will be various activities as part of the LOGOS and youth programs run by Northbrook Presbyterian Church and that participation in such activities is strictly voluntary.  I hereby release Northbrook Presbyterian Church and its employees, agents, representatives and volunteers from any and all responsibilities for any accidents or injuries that might occur during such activities.
By checking this box I certify that my child has has permission to participate in LOGOS and youth programs sponsored by Northbrook Presbyterian Church September 2023 and August 2024.  I agree that during such times as my child will be under the supervision of the adult leadership at the Northbrook Presbyterian Church that in the event of serious misbehavior, my child may be sent home prior to the end of the activity.
By checking this box I certify that adult supervision at Northbrook Presbyterian Church will have the right to request and obtain medical treatment for my child in the event of illness or injury which renders such treatment necessary or advisable.  This authorization shall remain in effect while my child is under adult supervision at Northbrook Presbyterian Church.
By checking this box, I understand that in the event of an emergency every effort will be made to contact parents or guardians.  In the event I cannot be reached, I hereby give permission to hospitalize, secure treatment for and/or order injection, anesthesia, or surgery for the youth named above.  If I cannot be reached, I authorize the Church, or its agents, to consent to any diagnosis, examination, treatment or hospital care for the youth named above which is deemed advisable by and is rendered under the supervision of a physician.  
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