2023-2024 Youth Registration Form

Parent/Guardian Information

Parent/Guardian (#1)

Relationship to Child

Phone #1

Phone #2

This address will receive a confirmation email

Address

Parent/Guardian (#2) First Name

Last Name

Relationship to Child

Phone #1

Phone #2

Address

Child Information

Child (1): First Name

Last Name

Gender

Male Female

Patron Saint / Name Day

Date of Birth (Month/Day/Year)

Name of School & District

Please List and Describe your Youth's Allergies, Dietary Restrictions, Medical Conditions, and Special Needs (Write N/A if Not Applicable)

Please Note Anything Else that we Should Know about your Youth that will Help Him/Her Succeed in our Programs: Ex. Learning/Behavioral/Social Concerns (Write N/A if Not Applicable)

I give permission for photos of my child to be used in St. Nicholas publicity

Yes No

Child (2): First Name

Last Name

Gender Male Female

Patron Saint / Name Day

Date of Birth (Month/Day/Year)

Name of School & District

Please List and Describe your Youth's Allergies, Dietary Restrictions, Medical Conditions, and Special Needs (Write N/A if Not Applicable)

Please Note Anything Else that we Should Know about your Youth that will Help Him/Her Succeed in our Programs: Ex. Learning/Behavioral/Social Concerns (Write N/A if Not Applicable)

I give permission for photos of my child to be used in St. Nicholas publicity Yes No

Child (3): First Name

Last Name

Gender Male Female

Patron Saint / Name Day

Date of Birth (Month/Day/Year)

Name of School & District

Please List and Describe your Youth's Allergies, Dietary Restrictions, Medical Conditions, and Special Needs (Write N/A if Not Applicable)

Please Note Anything Else that we Should Know about your Youth that will Help Him/Her Succeed in our Programs: Ex. Learning/Behavioral/Social Concerns (Write N/A if Not Applicable)

I give permission for photos of my child to be used in St. Nicholas publicity Yes No

Child (4): First Name

Last Name

Gender Male Female

Patron Saint / Name Day

Date of Birth (Month/Day/Year)

Name of School & District

Please List and Describe your Youth's Allergies, Dietary Restrictions, Medical Conditions, and Special Needs (Write N/A if Not Applicable)

Please Note Anything Else that we Should Know about your Youth that will Help Him/Her Succeed in our Programs: Ex. Learning/Behavioral/Social Concerns (Write N/A if Not Applicable)

I give permission for photos of my child to be used in St. Nicholas publicity Yes No

Child (5): First Name

Last Name

Gender Male Female

Patron Saint / Name Day

Date of Birth (Month/Day/Year)

Name of School & District

Please List and Describe your Youth's Allergies, Dietary Restrictions, Medical Conditions, and Special Needs (Write N/A if Not Applicable)

Please Note Anything Else that we Should Know about your Youth that will Help Him/Her Succeed in our Programs: Ex. Learning/Behavioral/Social Concerns (Write N/A if Not Applicable)

I give permission for photos of my child to be used in St. Nicholas publicity Yes No

Non-Parental Emergency Contact Information

First and Last Name

Relationship to Child

Phone

Medical Information: Physicians/Medical Offices will Only be Contacted in the Event of an Emergency and if Parents/Emergency Contacts Cannot be Reached.

If your Children have Different Physicians, Please Indicate as Necessary.

Primary Physician

Physician/Medical Office Name

Physician's Phone

Preferred Hospital

Signature of Consent

I hereby acknowledge that all of the information provided by myself in this e-form is accurate and true to the best of my knowledge.

I understand that is my full responsibiity to notify the Youth Director of St. Nicholas Orthodox Christian Church should ANY changes occure with the information I have provided in this e-form.

By providing my name below, I am offering my legal signature and am consenting to the use of this e-form by the Youth Director and Youth Ministry Team of St. Nicholas Orthodox Christian Church.

First and Last Name

2023-2024 Youth Registration Form

Description

Please Fix the Following