Name *

First Name

Last Name

Parent Name *

First Name

Last Name

Parent Phone *

(###)

###

####

Emergency Contact (Other than parent listed above) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Friend's name (if attending with a friend)

First Name

Last Name

Medical Concent *

As parent/guardian of child listed above I give St. John's Lutheran (and designated adults) permission to medically treat my child and I know I will be attempted to be contacted if an emergency should arise.

Agree