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
NAME OF PARENTS OR CAREGIVER
HOME ADDRESS (include city, state & zip code)
YOUTH PHONE NUMBER (specify home or cell)
PARENT OR CAREGIVER PHONE NUMBER (specify home or cell)
PRIMARY EMAIL ADDRESS
DATE OF BIRTH (include Month/Day/Year)
ALLERGIES or MEDICAL ISSUES
SPECIAL NEED RESTRICTIONS
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.
HOSPITAL PREFERENCE (choose one)
Other: Please note in Emergency Contact section
EMERGENCY CONTACT NAMES & NUMBERS IN CASE PARENT CANNOT BE REACHED:
MAY YOUR YOUTH'S PHOTO BE INCLUDED IN MOOSE LAKE COVENANT PUBLICATIONS OR WEBSITE?
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