St. Matthews Youth Programs Registration
Youth Group, Fellowship Groups, Sunday School, Bible Study, Worship Teams
Youth Participant Name *
Your answer
Youth Participant Information- birth date *
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Youth Participant Information- Age *
Your answer
Youth Participant Information- Sex *
Your answer
Youth Participant Information- School *
Your answer
Youth Participant Information- Grade *
Address *
Your answer
Home Phone Number *
Your answer
Youth Cell Phone Number
Your answer
Primary Contact- Parent/ Guardian- Name *
Your answer
Primary Contact- Phone Number/s *
Your answer
Primary Contact Email
Your answer
Secondary Contact- Parent/ Guardian- Name
Your answer
Secondary Contact- Phone Number/s
Your answer
Secondary Contact- Email
Your answer
I would like to be added to text message reminders of events for all programs involved. *
Emergency Contact- if neither parent/guardian can be reached in the event of an emergency- Name, relationship- phone # *
Your answer
Programs you are registering for- check all that apply *
Required
Doctor
Your answer
Phone Number
Your answer
Do you have health insurance?
Name of Insurance Company
Your answer
Phone Number- Insurance Company
Your answer
Policy Number- Insurance Company
Your answer
Address- Insurance Company
Your answer
Health History (This information is confidential, and only shared with adult leaders in this situation). Allergies
Health History (This information is confidential, and only shared with adult leaders in this situation). Other Conditions
If you checked any of the above, please give details that will help us care for youth (include normal treatment of allergic reactions)
Your answer
Name and Dosage of any medications that must be taken on a regular basis.
Your answer
Any swimming restrictions?
Any activity restrictions?
If so, what restrictions?
Your answer
Date of last Tetanus Shot
MM
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DD
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YYYY
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