Registeration for 2023 YIC Mission TripJune 2-10, 2023 Youth Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Youth Date of Birth (MM/DD/YYYY) * MM DD YYYY Youth Cell Phone Number * (###) ### #### Parent's Email * Photograph & Video Release Form: As parent or guardian, I give my permission for my child(ren) to be photographed and/or videotaped and used by Holy Word Lutheran Church and its Representatives. * Yes No Food/Medication Allergies * Please type NA if none. Drug Allergies * Please type NA if none. Medical Conditions * Please type NA if none. Medications Currently Taking? (Please include dose amounts and times to be taken. EX: Hydrocortisone 5mg Tablet - 6a-3.25mg, 2p-3.25mg, 10p- 2.5mg) * Please type NA if none. I authorize trip leaders and chaperones to give my child Tylenol or other non-prescription medication as needed for minor illness or discomfort. * Yes No Parent(s) or Legal Guardian(s) Name(s) * Parent(s)/Guardian(s) Phone Numbers * Please include a number for each parent or guardian. Youth Physician Name * First Name Last Name Youth Physician Phone Number * (###) ### #### Whom shall we notify if we are unable to contact mother, father, legal guardian, or family physician? * Please include Name, Address, Telephone, and Relationship to Youth * Please include Name, Address, Telephone, and Relationship to Youth Health Insurance Provider * Health Insurance Number * As a parent or guardian, I do herewith authorize Chad White and/or Cindy White to send my child (properly accompanied) to an available hospital or physician. I also authorize the treatment by a qualified and licensed medical doctor of the above-named minor, in the event of a medical emergency, which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. Necessary first aid may be given by one of the above before reaching the hospital/physician. This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence on the Youth In Christ Mission Trip, June 2-10, 2023. By checking below, I hereby certify that the above statements are true and correct to the best of my knowledge. I state that this release form is completed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence on the Youth In Christ Mission Trip, June 2-10, 2023. * Please type your full name into the box below indicating that you have read and agree with the above paragraph. Thank you!
