• • Sunday School 2012 - 2013

    Registration & Medical Release Form
• • Child's Name *
    
    First
    
    Last
• • Birthdate *
    
    
• • Age *
    
    
• • Grade in Fall 2012 *
    
    

• • Parent/Guardian Information
• • Name *
    
    First
    
    Last
• • Address *
    
    Street Address
    
    Other Address (optional)
    
    City
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    State/Province
    
    Zip/Postal Code
    
    Region (optional)
    ...United StatesCanadaJapanUnited KingdomAustraliaGermanyFranceSwitzerlandItalyNetherlandsAlbaniaAlgeriaAmerican SamoaAndorraAnguillaAntarticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBouvet IslandBrazilBritish Indian Ocean Terr.Brunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslColombiaComorosCongoCook IslCosta RicaCote D'IvoireCroatiaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFaeroe IslandsFalkland Isl. (Malvinas)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey C.I.GuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsle of ManIsraelItalyJamaicaJapanJersey C.I.JordanKazakhstanKenyaKiribatiKorea Republic ofKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxemborgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslMartiniqueMauritaniaMauritiusMexicoMicronesiaMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslNorthern Mariana IslNorwayOmanPakistanPalauPanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts & NevisSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSt. Vincent & GrenadinesSurinameSvalbard & Jan Mayen IslSwazilandSwedenSwitzerlandTaiwanTajikistanTanzania United RepublicThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslTuvaluU.A.E.U.S.Minor Outlying IslUgandaUkraineUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican City StateVenezuelaViet NamVirgin Isl (British)Virgin Isl (U.S.)Wallis & Futuna IslandsWestern SaharaYemen Republic ofZaireZambiaZimbabwe
    Country
• • Home Phone
    
    
    
    
    
    
• • Cell Phone *
    
    
    
    
    
    
• • Email
    
    
• • Siblings attending Sunday School
    
    

• • Emergency Contact Information

    (if Parent/Guardian is not available)
• • Name *
    
    First
    
    Last
• • Phone Number *
    
    
    
    
    
    
• • Relationship *
    
    
• • Other people allowed to pick up my child
    
    First
    
    Last
• • Phone Number
    
    
    
    
    
    

• • Medical Information
• • Please list any allergies (medications, foods, etc.) *
    
    
• • Does your child have any medical or special needs including medications? *
    ...YesNo
    
• • If yes, please explain:
    
    

• • Medical Authorization - Please select the "agree" button to confirm the below statement:

    I (we) the undersigned parent(s) or guardian(s) of the student listed above, do hereby authorize adult workers of Holy Cross Lutheran Church, Livermore, as agent(s) for the undersigned to consent to any medical or surgical care deemed advisable by any physician or surgeon licensed under the provision of the Medical Practice Act on the medical staff of any hospital.
• • Agree *
    ...I agree
    

• • Registration & Photo Release Authorization

    My child had my permission to attend and participate in the Sunday School program. His/her photo may be taken during activities and included in the Church newsletter or webpage. He/she may go on a walking excursion to Mocho Park down the street with adult supervision.
• • Agree *
    ...I agree
    

• • Parent/Guardian Signature
• • Name
    
    First
    
    Last
• • Date
    
    

Authentication Text*
(Enter the text in the image above into this field.)

NOTE: Do Not Alter These Fields: