REGISTRATION-YOUTH SPORTS CENTER – HOLY CROSS LUTHERAN CHURCH

Participant Information

Child's First Name *

Child's Last Name *

Preferred Name

Child's Date Of Birth

Child's Age: *

Child's School

Child's Grade

Home Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Primary Language, if other than English:

Health, Allergy, and Medical Information

Does your child have any allergies? *NoYes

If yes, please describe the allergy, severity, triggers, and response plan:

Does your child carry or require emergency medication, such as an EpiPen, inhaler, seizure medication, or other medication? *NoYes

If yes, please describe:

Does your child have asthma, diabetes, seizures, heart condition, respiratory condition, mobility limitation, sensory sensitivity, anxiety, trauma-related concern, or other medical condition Holy Cross should know about? *NoYes

If yes, please describe:

May Holy Cross contact emergency medical services if needed? *NoYes

Physician / Medical Provider Name:

Physician / Medical Provider Phone:

Health Insurance Carrier, optional:

Policy / Member Number, optional:

Special Needs, Accommodations, and Support

Does your child have any special needs, learning differences, behavioral supports, emotional supports, accessibility needs, communication needs, or accommodations that would help your child participate safely and successfully? *NoYes

If yes, please describe:

Are there any strategies that help your child during transitions, group activities, stress, sensory overload, conflict, or emergencies? *NoYes

If yes, please describe:

Is there anything Holy Cross should know related to the Palisades Fire, displacement, loss, trauma, or recent family circumstances that may affect your child’s participation? *NoYes

If yes, please share anything you would like us to know:

Emergency Contacts & Authorized Pick-Up Persons

Emergency Contact Information

Emergency Contact Name (1): *

Emergency Contact Phone (1): *

Relationship to Child (1):

Emergency Contact Name (2): *

Emergency Contact Phone (2): *

Relationship to Child (2):

Email Address *

Phone Number

City

Authorized Pick-Up Persons

Authorized Pick-Up Name: *

Relationship:

Authorized Pick-Up Phone: *

Persons not authorized to pick up the child, if any:

Parent / Guardian Permissions and Acknowledgements

May Holy Cross use photographs or video of your child for internal, community, or program-related communications? *Photo, Video, and Media PermissionNoYesPlease contact me before any use

If yes, any limitations:

Registration Options & Pricing

Please ensure you have selected "How many children are you registering today? *" in order to display options and pricing in this section.

Number of Prorated Days *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email Address *

Date

Notes about attendance:

Total Amount Due Today

Payment Method: *Credit CardCheckACHOther:

ONLINE OR MAIL-IN REGISTRATION - YOUTH SPORTS CENTER

ONLINE REGISTRATION

Health, Allergy, and Medical Information

Special Needs, Accommodations, and Support

MAIL-IN REGISTRATION

ONLINE OR MAIL-IN REGISTRATION - YOUTH SPORTS CENTER

ONLINE REGISTRATION

MAIL-IN REGISTRATION

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