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Registracion del Participante

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St. Mark Lutheran Church

Location

1822 E. Grand Ave.

Lindenhurst, IL 60046

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Contact Deb Heide:

847-356-8140

heidedeborah@gmail.com

Primero, cuéntenos sobre usted:

Información de los Padres

Nombre

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Apellido

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Correo Electrónico

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Dirección 1

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Dirección 2

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Ciudad

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Estado/Provincia

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ZIP/Código Postal

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Teléfono de Contacto 1

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Nombre del Contacto de Emergencia

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Relación del Contacto de Emergencia

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Teléfono del Contacto de Emergencia

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Nombre de recogida alternativo

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Teléfono de recogida alternativa

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Afiliación de la iglesia local

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Cuéntanos sobre tu participante

Parents/Guardians:

Please remember to provide your full name and date in the Emergency Medical Treatment and Photo/Media Waiver permission fields at the end of the Participant information list.

You must fill these out for your registration to be complete. If you choose not to have your child photographed or in videos, please just type "I do not give permission," and then add your name and date.

Thank you!

Nombre

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Apellido

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Grado Entrando

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Género

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Fecha de nacimiento

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Alergias

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Preocupaciones Médicas

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[Full name and date needed.] FAMILY AUTHORIZATION and CONSENT TO EMERGENCY MEDICAL TREATMENT: Please provide your full name and date. Family Authorization and Consent to Emergency Medical Treatment: Being the parent or legal guardian of the enrolled minor child, I consent to any medical, surgical, x-ray, anesthetic or dental treatment that may be deemed necessary for my minor child during St. Mark Parents' Morning Out. I understand that efforts will be made to contact me prior to treatment, but in the event I cannot be reached in an emergency, I give permission to the Parents' Morning Out staff to make the necessary decisions for treatment. I give permission to the attending physician to treat my minor child. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental or hospital care or treatment that is given to my minor child. Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage.

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[Full name and data needed.] PHOTO/MEDIA WAIVER: I hereby give St. Mark Lutheran Church, Lindenhurst, IL, consent to take photographs and/or videos of my child(ren) for promotional purposes in print, on the St. Mark Lutheran Church website, Facebook page, monthly newsletter, or worship media for the Parents' Morning Out ministry.

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