United Youth Registration Form 2020-21

Youth Information

Name

Phone

Address

Grade

Gender

Male Female

Age

Birthdate

Allergies

Special Needs

Parent Information

If not applicable, please put n/a.

Mother's First Name

Mother's Last Name

Mother's Phone Number

Father's First Name

Father's Last name

Father's Phone Number

Parent Email Address

This address will receive a confirmation email

Pick-up Information

Please list who you (the parent/legal guardian) authorize - other than yourself or spouse - to pick-up your child from United Youth.

Authorization #1 - First Name

Authorization #1 - Last Name

Authorization #1 - Phone Number

Authorization #2 - First Name

Authorization #2 - Last Name

Authorization #2 - Phone Number

Authorization #3 - First Name

Authorization #3 - Last Name

Authorization #3 - Phone Number

Medical Information

In case of an emergency, United Youth Director, has the permission to administer the following medication to my child.

Please check the following medication that you approve for your child. Please type any specifications or notes in the "notes" section at the bottom.

Medication

Tylenol Motrin Benadryl Topical Antibiotic Ointment I do not authorize any medications to be administered

Notes:

Signature

In the event that all reasonable attempts to contact me have been unsuccessful, I give my consent to the administration to my child of any medical treatment deemed necessary by a licensed physician and the transfer of my child to any hospital reasonably accessible. I understand and agree that Calvary Baptist Church does not assume responsibilty for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.

Printed Parent/Legal Guardian Full Name

Date

Description

Please fill out this form to register your student for United Youth.

United Youth Registration Form 2020-21

Description

Please Fix the Following