In addition to completing this form, please provide photos of the back and front of your health insurance card to Donna Snyder (email to, put in envelope in secure dropbox by office door, or hand to her directly).

    Participant's Name (required)*

    Date of Birth*





    Parent or Guardian Name*

    Your Email*

    If the church office already has the following, please skip to 'Emergency Contact Information'.





    Home Phone

    Cell Phone

    Emergency Contact Information*


    Cell Phone*

    Health Insurance Information

    Name on Insurance*

    Employer (if applicable)

    Insurance Company*

    Group or Plan#


    Insurance Address

    Insurance Phone*

    Allergies to medication, food, insects, or environment

    Please describe symptoms/severity of allergy

    Health History

    Any physical health needs or conditions we should be aware of? (sleepwalking, recent illness or injury, seizures, history of infections)

    Any emotional or social adjustment issues which we should be aware of in order to provide the best care possible and facilitate participation in the group

    Any mental or emotional health issues that could lead to violence, high anxiety, or in any other way affect participation in the event

    I understand that participants must be in good health when arriving at an event. If a participant is found to have a fever, head lice, or unexplained rash, the parent/guardian will be asked to take her or him home.
    Drivers must stay until participants have been fully checked in.

    Please enter your full name to indicate your permission*:

    I hereby authorize approved adult leaders of Cross of Life Lutheran Church to consent to any medical treatment, dental treatment, or hospital care to be rendered to the child named aboveunder the general or specific supervision and under the advice of any licensed physician, dentist, or surgeon. It is my understanding that if the nature of the emergency allows for the time or opportunity, attempts will be made to contact me at the phone numbers provided above before any treatment by physician, surgeon, dentist, or surgeon, or hospital. I understand that in the event my child is injured or becomes ill and it is necessary for him/her to receive medical or dental treatment that my health, dental and accident insurance will be used to cover such expenses and that I will be responsible for any such expenses not covered by my insurance.