Youth Event Form Number of Children To Register*1234Student 1Student's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2024-25)*6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDate of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsStudent 2Student's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2024-25)*6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDate of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsStudent 3Student's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2024-25)*6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDate of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsStudent 4Student's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2024-25)*6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDate of last tetanus shot MM DD YYYY AllergiesMedicationsAdditional Notes or CommentsParent / Guardian InformationRelation*FatherMotherGuardianIf Guardian, relationship to child (or children)*Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Phone or Cell Phone*Work PhoneAdd Another Guardian/Parent YES Parent / Guardian InformationRelation*FatherMotherGuardianIf Guardian, relationship to student (or students)*Name* First Last Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Phone or Cell Phone*Work PhoneEmergency ContactsName* First Last Phone*Relationship*Name* First Last Phone*Relationship*Medical Release / PermissionAgreement*I give permission for each child listed above to participate in the Discovery Hills Church Youth Events. I agree *In the event I cannot be reached in an emergency, I give Discovery Hills Church Staff permission to consent to any x-ray, examination, anesthetic, or medical or surgical services needed on the advice of a physician or surgeon licensed to practice in the state of treatment when the need for such treatment is immediate. I agree Please type your full name as a consent*Today's Date* MM DD YYYY Medical InformationPhysician's Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy #Additional notes, restrictions, etc.