GYM & GYL Registration Form

Youth’s name *
Parent’s name(s) *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *
Email
Age *
Grade level *
School child attends
Church child attends

Please state any conditions that might limit your child's activities *
Is your child currently taking any medications? If so, please specify *
Does your child have any allergies (please include medicine and foods) *
Does your child carry any medicine on his/her person? If so, please specify *
I, the parent or legal guardian, of the child named on page 1, hereby grant my permission for him/her to participate in the GYM & GYL Program. I acknowledge the fact that he/she is physically able to participate in group activities. I release Living Abundantly Ministries, its employees, Board of Directors, Volunteers, and/or sponsors form all claims from injuries or illnesses which may be sustained by my child due to any participation, transportation in effect of any other of the activities thereof, and authorize treatment of the above named participant on an emergency basis in the event that such treatment becomes necessary. I also give my permission for any picture taken of my child to be used in presentations and publicity. I understand that any identifying information such as my child’s name will not be used in the pictures. I give consent for my child to ride on the buses or church vans that may be used by Living Abundantly Ministries for the GYM & GYL program. I affirm that I have received a copy of this document.
Electronic Signature (Please type name here) *
Date