2021 Child & Youth Registration Form

2021 Child & Youth Registration Form
Thank you for your interest in enrolling your child or youth in Messiah's many fellowship and faith formation programs for young people! This form is to be updated at the beginning of each program year and will help us properly serve you and your child or youth. Information will be kept securely on JotForm's HIPAA compliant website as well as privately within Messiah's secure Realm virtual directory and will only be shared with relevant faith formation staff and volunteers, particularly when traveling offsite. Please be sure information is as accurate as possible. Parents or guardians are responsible for updating this information if it changes throughout the program year (i.e. changes to allergies, medical history, emergency contact information).
Child/ Youth's Name: *
First, Middle, Last Name
Child/ Youth's Age: *
Child/ Youth's Date of Birth: *

Month Day Year
Date
Child/ Youth's Grade: *
Child/ Youth's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Youth's Mobile Phone Number:
Messiah staff and volunteers may occasionally contact your youth over thirteen years of age about upcoming events and other programming with a parent's permission. All contact with minors is to be strictly conducted in line with Messiah's SafeChurch Policy.
Parent/ Guardian Information

Please list your name and contact information and the name and contact information for a second parent/ guardian, if applicable.
Parent/ Guardian Name: *
Parent/ Guardian Mobile Phone Number: *
Parent/ Guardian Email Address: *
example@example.com
Second Parent/ Guardian Name (if applicable):
Second Parent/ Guardian Mobile Phone Number (if applicable):
Second Parent/ Guardian Email Address (if applicable):
example@example.com
Is there a court order in place that lists certain persons who are not authorized to pick up your child/ youth from Messiah? If so, please list names of those persons below. *
Emergency Contact Information

Please list, in order, two persons that we can contact in the event of an emergency. We will call the first person listed first and continue down the list until we have made contact.
Name: *
Mobile Phone Number: *
Relationship with Child/ Youth: *
Name: *
Mobile Phone Number: *
Relationship with Child/ Youth: *
Healthcare Provider Information

Please fill out the following information so we can properly assist your child/ youth in case of a medical emergency, particularly if on a trip outside of regular faith formation hours.
Child/ Youth's Physician Name: *
Child/ Youth's Physician Phone Number: *
Child/ Youth's Insurance Company: *
Child/ Youth's Insurance Company Phone Number: *
Child/ Youth's Insurance Policy Number: *
Medical History

Please complete the following basic medical information about your child/ youth to help our staff and volunteers keep them healthy and safe.
Does your child/ youth have any of the following conditions? *

None Asthma Bleeding/ clotting disorder Convulsions in last 60 days Diabetes Epilepsy/ seizures Frequent ear infections GI Tract issues Heart defect/ disease Hypertension Sickle cell Neurological illness
If you checked any of the conditions above, please explain below:
Is your child allergic to any of the following items or have any of the following dietary restrictions? *

None Peanut allergy Shellfish allergy Celiac disease Vegan Vegetarian Bee sting allergy Tree nut allergy Soy allergy Penicillin allergy Dairy intolerance Gluten intolerance Egg allergy Milk allergy No pork
If you checked any of the conditions above, please explain below:
Does your child/ youth carry an epi-pen? *

Yes No
Does your child/ youth carry an inhaler? *

Yes No
Has your child/ youth had any of the following childhood diseases? *

None Chickenpox Measles Mumps Hepatitis A Hepatitis B Hepatitis C Mononucleosis Whooping cough
Date of your child/ youth's last Tetanus shot or booster: *

Month Day Year
Date
Is there anything else you would like for us to be aware of relative to your child/ youth’s health or past medical history? *
Permission to Treat, Photo Release and Waiver
Please check the over-the-counter medications that are acceptable for your child/ youth to take if needed: *

Benadryl Pepto Bismol Ibuprofen (Advil/Motrin/ generic) Acetaminophen (Tylenol or generic) Tums Antihistamine ( Benadryl, Zyrtec, Claritin or generic)
By signing below, the parent/legal guardian of the above named child/ youth, authorizes the Evangelical Lutheran Church of the Messiah (hereafter Messiah Lutheran Church) staff and/or volunteers and the medical personnel they have selected to consent to any medical/hospital care deemed necessary. The parent/legal guardian further consents to the release of this health history to the emergency room, hospital or doctor’s office providing care. Messiah will endeavor, but is not required, to communicate with the parent/ legal guardian prior to treatment. The undersigned releases Messiah and its staff and/or volunteers from any liability and claims arising from any consent given in good faith and in connections with diagnosis or treatment.
By signing below, the parent/legal guardian of the above named child/ youth, authorizes Messiah Lutheran Church and its staff and/or volunteers to utilize appropriate photographic and/or video images of the child/ youth in line with Messiah's SafeChurch policy. The parent/legal guardian understands that neither they nor the child/ youth will receive compensation, should any photograph and/or video of my child be published. The undersigned, as parent/legal guardian of the above named youth, hereby release, forever discharge and agree to hold harmless Messiah Lutheran Church, its staff and/or volunteers from and against any and all kind of liability, claims, demands, lawsuits, and expense of any kind arising from personal injury, sickness, death or property damage of any kind whatsoever which may be incurred or by virtue of the child/ youth’s participation in faith formation, fellowship and other programming at Messiah Lutheran Church. The undersigned certifies they have full authority to sign this Permission to Retreat, Photo Release and Waiver.
Parent/ Guardian Printed Name *
Parent/ Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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2021 Child & Youth Registration Form

Parent/ Guardian Information

Emergency Contact Information

Healthcare Provider Information

Medical History

Permission to Treat, Photo Release and Waiver