Participant's Name (Required)

Birth Date of Participant (Required)

Gender (Required)

Name of Parent / Guardian (Required)

Address (Required)

Day Phone (Required)

Night Phone (Required)

Medical Insurance, name and policy # (Required)

Emergency Contact (Required)

Does this participant have any physical, psychiatric, emotional or behavioral condition of which the youth group advisor should be aware? (Required)

Restrictions on activities (Required)

Regularly prescribed medications and doses (Required)

Date of most recent tetanus booster (Required)

Allergies or Medical Info (Required)

Photo Release: Photos of my child may be used in OSLC publications and social media (without names or other identifying information). (Required)

This health history is correct to the best of our knowledge. The person herein described has my permission to engage in all prescribed activities except as noted above. The following authorization empowers the staff of Our Saviour’s Lutheran Church, Stanwo (Required)

Please type your name (this serves as your signature) (Required)