Central Youth Group Registration

General Information

Youth Name*

Mailing Address*

Youth Cell Number*( ) -

Youth Email*

Parent/Guardian Name*

Parent/Guardian Cell Number*( ) -

Parent/Guardian Email*

Relationship With Youth*

Parent/Guardian Name

Parent/Guardian Cell Number( ) -

Parent/Guardian Email

Relationship With Youth

Grade*

Youth grade of fall 2023

Youth Birthday*

What School Do You Attend?*

T-Shirt Size*

Health Information

Insurance Company Name*

Policy Holder Name*

Policy Number*

Insurance Authorization Phone Number

Family Physician Name

Family Physician Phone Number( ) -

Year of Last Tetanus Shot*

Allergies

Current Medications (If Any)

Any Other Info We Should Know?

Consent For Medical Treatment

By typing my name below, I authorize my consent*

Please read medical release form before authorizing your consent

Please leave this field blank.