Wednesday Nt Youth Registration & Medical Form Family Name Last Child 1 Name* First Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade Entering in the Fallplease choose one from the list below6th7th8th9th10th11th12thAdditional informationPlease provide any additional information you deem helpful about your child.Child 2 Name First BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade Entering in the Fallplease choose one from the list below6th7th8th9th10th11th12thAdditional informationPlease provide any additional information you deem helpful about your child.Child 3 Name First BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade Entering in the Fallplease choose one from the list below6th7th8th9th10th11th12thAdditional informationPlease provide any additional information you deem helpful about your child.Parent/Guardian Name(s)* First Last Best Contact Phone Number*Alternate Phone NumberEmail* Hospital / Clinic Preference Physician's Name First Last Physician's Phone NumberInsurance Company Insurance Policy Number Allergies / Reactions / Special Health Considerations / Dietary Restrictions & important informationFront of insurance cardMax. file size: 100 MB.Please provide a copy of the front of your insurance cardBack of insurance cardMax. file size: 100 MB.Please provide a copy of the back of your insurance card.Consent form* Consent for emergency medical treatmentI authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached by Silverdale Lutheran Advisors in the case of an emergency. I agree to pay all medical costs in such emergency treatment. Covid Waiver* By checking this box I agree to the Covid Waiver. SLC will comply with the WA State Governor’s guidelines for employers and faith-based organizations during this time and until further notice. SLC cannot guarantee that you will not become infected with COVID-19 as a result of your presence on campus and assumes no liability with regard to the virus. Any individual, whether staff member, congregant, or group member, who wishes to be present at SLC must: Self-screen for signs/symptoms before entering the SLC campus, Wear a face mask that covers the nose and mouth, unless fully vaccinated. Practice good hygiene, washing hands with soap/water for at least 20 seconds, or use hand sanitizer (at least 60% alcohol content).CommentsThis field is for validation purposes and should be left unchanged.
