Children and Youth Registration Form

Child's Name*

First Middle Last

Child's Date of Birth*

Child's Preferred Pronouns*

He/Him
She/Hers
They/Them
Other:

Other Prounoun:

Child's Grade*

Parent/Guardian Name(s):*

Best Phone Number to Contact You*

Second Best Phone Number to Contact You

Parent/Guardian Email 1*

Parent/Guardian Email 2

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact:*

First Last

Emergency Contact Relation*

Emergency Contact Phone*

Who is authorized to pick up your child?

Who is NOT authorized to pick up your child?

Child's Insurance Policy

Name of Policy Holder

Employer Policy Holder

Policy Number

Group Number

Child's Physician*

First Last

Physician's Phone Number*

Is you child allergic to anything?*

Yes
No

If yes, please explain.

Does your child have a medical condition we need to know about?*

Yes
No

If yes, please explain.

Does your child take medication(s) regularly?*

Yes
No

If yes, please list.

Are your child's immunizations up to date?*

Yes
No

Is there anything else you would like us to know about your child?*

Yes
No

If yes, please explain.

I certify that this information listed above is true and correct to the best of my knowledge.

Consent*

I have read and agree to Calvary’s Medical Release, Waiver Form, Media Release, and Parent Manual Guidelines.

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Children and Youth Registration Form

Children/Youth Registration Form

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