RALLY and RYOT Registration Form

Use this form to register students in grades 6-12 for participation in RALLY and RYOT.

  
Name
  
Gender
  
  
Address
  
City
  
State
  
Zip Code
  
Home Phone
  
Youth's Cell Phone
  
Youth's Email
  
Date of Birth
  
Age as of August 1, 2019
  
School Grade 2019-20
  
  
T-Shirt Size
  
  
Parent / Guardian Name
  
Parent / Guardian Cell Phone
  
Parent / Guardian Work Phone
  
Currently Taking Medications
  
Allergies or other medical issues we should know about?
  
The adult leaders often carry some over-the-counter medications with them on outings. Please check any OTC medications that we may give to your child if necessary.
  
  
Health Insurance Company
  
Address
  
Phone
  
Policy Number
  
Group Number
  
Family Doctor
  
Phone
  
Emergency Contact 1
  
Phone
  
Emergency Contact 2
  
Phone
  
By my electronic signature below, I grant permission for my son/daughter to participate fully in any activities or trips sponsored by Resurrection Lutheran Church. I understand my signature carries with it the following:

1) An authorization of any the adult leaders to obtain medical attention and/or treatment for my son/daughter.

2) I knowingly release, absolve, indemnify and hold harmless Resurrection Lutheran Church from all claims that might result from any injury or death of any minor.

3) Should Medical help be needed, I agree to pay either directly or through my own health and accident insurance policy all medical and/or hospital costs.

4) I give Resurrection Lutheran Church permission to use any photograph/video of my child during any activities in future promotional materials, new releases or websites.

  
Electronic Signature
  
Today's Date

1919 Independence Pkwy Plano, Texas 75075 USA
Contact Us
972-867-0460    972-758-7921 (fax)
8:30 - 4:30 M-F
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PURPOSE: To unite as many persons as will share its confession of faith in a fellowship of Worship, Learning, Witness and Service that the Word of God in Jesus Christ may become effective in their lives together and individually.