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.
Clear selection
Youth's Information
Full Name *
Current School Grade *
List any health problems *
Allergies *
Dietary needs *
What medications, if any, are taken regularly and why? *
What are the medical procedures, including dosage and times, for these medications while your youth will be in our care?
Date of last Tetanus booster. *
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Physician's name *
Physician's phone number *
Dentist name *
Dentist phone number *
Preferred Hospital *
Medical Insurance Company *
Policy Number *
Parent's / Guardians Information
Name(s) *
Address *
Home Phone *
Work Phone *
Cell Phone *
Email Address *
1st Emergency Contact (other than parent or guardian) *
1st Emergency Contacts Phone Number *
1st Emergency Contacts Relationship to youth *
2nd Emergency Contact (other than parent or guardian) *
2nd Emergency Contact Phone Number *
2nd Emergency Contact Relationship to youth *
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. *
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. *
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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