Zion Lutheran Church

Youth Participant Registration Form

401 Riverview        Glendive, MT 59330

Name:                                                                                                                                                            
    First                                                                  Middle Initial                                   Last

Gender:           Male           Female                                                     Date of Birth:                                         

Mailing Address:                                                                                                                                              

Home Telephone:                                                          Cell Phone:                                                                

Email Address:                                                                                                                                                

Parent/Guardian’s Name(s):                                                                                                                            

Mother’s Work Phone:                                                                    Mother’s Cell Phone:                                           

Father’s Work Phone:                                                                    Father’s Cell Phone:                                            

Guardian’s Work Phone:                                                                 Guardian’s Cell Phone:                                        

Special Needs: Please indicate any special needs or disabilities that we should know about.  Include any medications needed or other necessary information with this form.  We will contact you with any questions.

Special Dietary Needs: Please indicate any special dietary restrictions such as vegetarian or food allergies.

Parent Permission Slip and Liability Waiver

I hereby allow my son/daughter/ward                                                               , for whom I am the legal guardian, to attend/participate in the                                                                                               event sponsored by Zion Lutheran Church, Glendive.

Release: I hereby agree my child/ren may participate in the above stated event.  I further agree to waive and release any claims I might have on behalf of myself or my child/ren for personal injury, property damage, property loss or death.  I discharge and release the Zion Lutheran Church, its officials, agents, employees, and volunteers from any liability, which might exist because of my child/ren’s participation in this event.  I also grant permission for the above named child/ren to ride in the provided vehicles that will be transporting the participants during this event.  I have read this Release and understand its terms.  I hereby sign this Release voluntarily and with full knowledge of its significance.

Signature:                                                                                                 Date:                                               

All students must have this completed form if they are to attend this event.

Thank you for your understanding and cooperation.

Page 2

Youth Emergency Medical Information & Waiver

This form must be completed for each youth participant.

This information is kept confidential and will be used only in case of emergency.

Name:                                                                                  Date of Birth:                                                       

Medical History:

Please answer the following questions: YES or NO

Does the participant currently have any physical complaints or chronic illness?

If yes, please list:                                                                                                                                               

Is the participant under the care of a physician or practitioner of any kind?

If yes, for what condition:                                                                                                                                   

Is the participant currently taking medications of any kind?

If yes, list medication and frequency of dosage:                                                                                               

Does the youth administer the medication on his/her own?  Yes   No

Is the participant current with his/her tetanus immunizations?

Date of last tetanus immunization:                                                              

Has the participant had any significant past injuries, illnesses, or surgeries?

If yes, please list what and when:                                                                                                                       

Does the participant suffer from allergies of any kind?

If yes, please list allergies and reactions:                                                                                                         

Additional Information: Please use this space to describe any additional relevant medical information not covered by the questions above.

Insurance Information:

Is the participant currently covered by medical insurance?  Yes    No

If yes, please list the name of the insurance provider:                                                                                                                            

Policy or Group #                                                                     Name of Primary Insured:                                                                     

Name of Physician:                                                                          Phone:                                                                                           

Medical Waiver:

  In the event of an emergency, I grant permission to Zion Lutheran Church staff or agents to transport my child/ward to a hospital/after hours clinic for emergency medical or surgical treatment.  I wish to be advised prior to any further treatment by the hospital or doctor.  As the parent/legal guardian, I give full authorization to the Zion Lutheran Church staff or agents to secure medical care or treatment for above named youth.  This treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate medical attention, as to determined by the event staff.  In the event that I cannot be contacted, and an emergency has occurred, I give permission to the treating medical institution and/or medical providers to hospitalize and administer the appropriate treatment deemed medically necessary.

  I further agree that Zion Lutheran Church and its employees and agents will not be held responsible for injuries or damages arising from the provision of any such emergency medical treatment.  I understand that as a parent/guardian, I will be responsible for the cost of any service of treatment provided.  This authorization shall remain effective until he/she completes this event.  I have read this document, I understand its contents, and I agree to its terms.  Please list any limits to medical treatment on the back of this signed sheet.

Signature of Parent/Guardian                                                                                                                                           Date