Youth Registration (Moose Lake Covenant Church)
Register for Moose Lake Covenant Youth Group (grades 6-12). Please register one youth at a time.
FIRST & LAST NAME OF YOUTH
Your answer
NAME OF PARENTS OR CAREGIVER
Your answer
HOME ADDRESS (include city, state & zip code)
Your answer
YOUTH PHONE NUMBER (specify home or cell)
Your answer
PARENT OR CAREGIVER PHONE NUMBER (specify home or cell)
Your answer
PRIMARY EMAIL ADDRESS
Your answer
DATE OF BIRTH (include Month/Day/Year)
Your answer
SCHOOL GRADE
ATTEND
ALLERGIES or MEDICAL ISSUES
Your answer
SPECIAL NEED RESTRICTIONS
Your answer
PARENT PERMISSION TO TREAT: In the event that I am not in the building and cannot be reached in an emergency, I hereby give permission to the program coordinator and Pastor to obtain emergency transport as needed to designated hospital.
DOCTOR'S NAME
Your answer
HOSPITAL PREFERENCE (choose one)
EMERGENCY CONTACT NAMES & NUMBERS IN CASE PARENT CANNOT BE REACHED:
Your answer
MAY YOUR YOUTH'S PHOTO BE INCLUDED IN MOOSE LAKE COVENANT PUBLICATIONS OR WEBSITE?
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