PHASE Registion Form
Student's Name: *

Student's grade

What PHASE is your child registering for? *

Student's Address: *

Birthdate: *

School: *

Parent/Guardians Name: *

Email Address: *

Home Number: *

Cell Phone Number *

Preferred method of communication *

Is your child Baptized? *

Is your child taking COMMUNION? *

Classmates you would like in your child's SMALL GROUP:

Parents, it takes many volunteers to make a program of this size happen for your child (ren).  Are you interesting in volunteering in one of the following areas? *


I am the parent/legal guardian of the participant, and hereby grant my permission for him/her to participate fully in Central Lutheran Church related trips and activities.

In the event of an emergency and I cannot be reached, I give permission for the supervising Central Lutheran staff or the available adult leader to sign forms that would ensure the NECESSARY and IMMEDIATE treatment of the participant.  I give permission to those administering emergency treatment to do so using those measures deemed necessary.  I furthermore absolve those acting on my behalf in this regard from liability as log as there is not gross negligence.  (Please contact Central Lutheran to clearly state treatment of your child in the even of an emergency if different than the instructions stated in this paragraph.)  

Further, I understand that the child-participant cannot use alcohol, tobacco, drugs, firearms, or fireworks at any Central Lutheran sponsored activities, regardless of location.  If those rules are broken, I hereby assume transportation costs incurred for immediately returning the student home.  

Name of other persons to contact in case of an emergency (if parent/guardian is unavailable to contact). *

Phone Number: *

Physician Name: *

Physician Number: *

Family insurance Company: *

Policy #: *

Allergies, physical limitations, pre-existing conditions, medication currently used, other comments:

Thank you for partnering with Central Lutheran.
Remember, it is just a PHASE, so don't miss it.
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