Registration and Authorization for Medical Treatment
By completing the online registration you are giving permission for your youth to participate in all activities of Evangelical United Church of Christ Sunday School Program.
Youth's Information
Full Name *
Your answer
Current School Grade *
List any health problems *
Your answer
Allergies *
Your answer
Dietary needs *
Your answer
What medications, if any, are taken regularly and why? *
Your answer
What are the medical procedures, including dosage and times, for these medications while your youth will be in our care?
Your answer
Date of last Tetanus booster. *
MM
/
DD
/
YYYY
Physician's name *
Your answer
Physician's phone number *
Your answer
Dentist name *
Your answer
Dentist phone number *
Your answer
Preferred Hospital *
Your answer
Medical Insurance Company *
Your answer
Policy Number *
Your answer
Parent's / Guardians Information
Name(s) *
Your answer
Address *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
1st Emergency Contact (other than parent or guardian) *
Your answer
1st Emergency Contacts Phone Number *
Your answer
1st Emergency Contacts Relationship to youth *
Your answer
2nd Emergency Contact (other than parent or guardian) *
Your answer
2nd Emergency Contact Phone Number *
Your answer
2nd Emergency Contact Relationship to youth *
Your answer
Consent
By typing your name (Parent or Guardian) you are giving your consent and permission to the following statement:
Information on this form will only be shared with medical personnel in case of an accident or emergency. In case of accident or emergency I give consent and authorization to an adult representative of Evangelical Church to obtain and authorize any and all medical, dental and/or surgical care and treatment for my child. If above physician is not available, I authorize such care and treatment to be preformed by any licensed physician or surgeon. Please type your full name and date below to accept these terms. *
Your answer
I give permission for pictures of my child to be used in church publications, church website, Facebook page or group, and local newspaper. Please type your full name and date below to accept these terms. *
Your answer
Would you like to receive text messages with Sunday School reminders? *
Be sure to Join our Facebook group for Sunday School updates and information! Search for EvUCC Sunday School News.
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