Children & Youth Registration • Living Hope Willmar

Child Specific Information

The following fields will be unique for each child.

First Name *

Preferred Name

Tip: This is the name that will be printed on their label.

Last Name *

Gender *

Date of Birth *

School Grade *

Tip: As of September 1st

Cell Number of Youth (7th-12th grade)

Email Address of Youth (7th-12th grade)

Special Needs Child *

Special Needs

Any Known Allergies? *

Allergies

Parent/Guardian #1 *

Tip: First & Last Name + Phone Number

Parent/Guardian # 2

Tip: First & Last Name + Phone Number

Emergency Contact

Tip: First & Last Name + Phone Number

Pick-Up Restrictions

Is there anyone who can NOT pick up this child?

Yes

Person Not Permitted #1 *

Tip: First & Last Name

Relationship to Child (#1) *

Is there a court order? (#1) *

Yes

Add another?

Yes

Person Not Permitted #2

Tip: First & Last Name

Relationship to Child (#2) *

Is there a court order? (#2) *

Yes

Family Contact Information

Please enter your family's contact information in the following fields. For your convenience, they will pre-fill when you add an additional child.

Phone Number

Email Address *

Tip: Parent/Guardian Email Address

Home Address *

Home City *

Home State *

Home Zip Code *

Is your mailing address different than your physical address?

Yes

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip Code *

Insurance Information

Do you have medical insurance? *

Yes

Insurance Provider *

Insurance ID# *

2023-2024 School Year Waiver

I (we), the parent(s) or legal guardian(s) of the child listed below, give my (our) child permission to fully participate in any event sponsored by Living Hope Evangelical Free Church of Willmar (Living Hope).

In the event that he or she is injured while participating in any event sponsored by Living Hope, I do hereby authorize and consent to any radiology, examination, anesthetic, medical, or surgical diagnosis rendered under general or special supervision of any licensed medical staff member. I understand that this authorization is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment, may deem advisable.

I understand that effort shall be made to contact me prior to rendering treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached.

I understand the nature of these events and do hereby release Living Hope, its staff, and representatives, from any liability for accident or injury sustained by my child in conjunction with these events.

I understand that video and/or photographs may be taken of activities sponsored by Living Hope. I give permission for all media (audio, video, and/or photographs) of my child to be used in church publications (bulletin, power point and/or bulletin boards, etc.) or on the Living Hope social media pages and website.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature *

Tip: By typing your name, you are signing the above stated waiver.

Waiver Signed Date *