Parent/Guardian 1
*
First Name
Last Name
Primary Phone (Emergency)
*
(###)
###
####
Email
*
Additional Contact (Parent/Guardian 2)
*
First Name
Last Name
Phone of Additional Contact
(###)
###
####
Email for Additional Contact
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Medical Insurance Holder
First Name
Last Name
Insurance Company Phone #
*
Insurance Phone #
(###)
###
####
Treatment Consent
*
Treatment Consent *
By selecting this checkbox, I/we, the parent/guardians of said child(ren) give permission for my/our children to participate in youth programs from September 2023 to May 2024 organized by Prince of Peace Lutheran Church of Schaumburg, Illinois. I/we understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form and/or the registration form. In the event I/we cannot be reached in an emergency, I/we hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or an injection, anesthesia, or surgery to my/our child(ren) as deemed necessary.
Insurance Consent
*
I/we understand that my/our insurance coverage for my child(ren) will be used as primary coverage in the event medical intervention is needed. Coverage by Prince of Peace Lutheran Church through its insurance policy is only a potential backup for what my/our family's insurance does not cover.
Liability Consent
*
I/we understand all reasonable safety precautions will be taken at all times by Prince of Peace Lutheran Church and its agents during the events and activities. I/we understand the possibility of risk. I/we agree not to hold Prince of Peace Lutheran Church, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred by the child(ren) on this form
Image Consent
*
I/we consent to the use of video images, photographs, audio recording, or any other visual or audio reproduction that may be taken of the child(ren) of this release during these programs to be used, distributed, or shown as Prince of Peace Lutheran Church sees fit.
True & complete
*
By checking this box, I/we attest as the parent and/or legal guardian of the above named child(ren), that the information provided on this form is true and complete.
Student Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Allergies/Medical Conditions
Important medical information that a caregiver should know, such as conditions, diet restrictions, allergies, or special considerations?
Current Prescriptions...
Health Needs
*
Is this person aware of his/her health care needs?
Contacts/Glasses
*
Does your student wear contacts or glasses?
Date of last tetanus shot
Please list the date of your student's last tetanus shot.
MM
DD
YYYY
Any additional information you would like us to know about the well being of your child?
Student Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Allergies/Medical Conditions
Important medical information that a caregiver should know, such as conditions, diet restrictions, allergies, or special considerations?
Current Prescriptions...
Health Needs
Is this person aware of his/her health care needs?
Contacts/Glasses
Does your student wear contacts or glasses?
Date of last tetanus shot
MM
DD
YYYY
Any additional information you would like us to know about the well being of your child?
Student Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Allergies/Medical Conditions
Important medical information that a caregiver should know, such as conditions, diet restrictions, allergies, or special considerations?
Current Prescriptions...
Health Needs
Is this person aware of his/her health care needs?
Contacts/Glasses
Does your student wear contacts or glasses?
Date of last tetanus shot
MM
DD
YYYY
Any additional information you would like us to know about the well being of your child?
