Registration Form

Shepherd of the Hills

Shepherd of the Hills Registration Form

If you have any questions about this form please contact Deacon Brian Henning.

* Indicates required field

Parent 1 Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Relation to Child *

Parent 2 Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Relation to Child *

Would you like to be added to the Faithful Adults email list? *

Yes No

Child Name *

First

Last

Date of Birth *

Date of Baptism *

Grade *

Child Name *

First

Last

Date of Birth *

Date of Baptism *

Grade *

Child Name *

First

Last

Date of Birth *

Date of Baptism *

Grade *

Consent Form

I am the parent or legal guardian of the child(ren) listed above, and I am informed of the activities offered by Shepherd of the Hills Lutheran Church located on 500 Blake Road South in Edina, MN, beginning on September 1st, 2019 and ending on August 31st, 2020. As parent or legal guardian of my child(ren), I hereby consent for my child(ren) to attend and participate in all on site activities provided by Shepherd of the Hills.

I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment.As parent or legal guardian of my child(ren), I am responsible for the health care decisions of my child(ren) and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child(ren) is legally sufficient and that no consent from any other person is required by law.

I am aware that photographs of my child(ren) may be taken and used on the Shepherd of the Hills website, Social Media pages, newsletter, bulletin, and/or other promotional and event sharing publications. Please contact Deacon Brian Henning if you do NOT want photos taken of your child.

Signature *

First

Last

Health Care Information

Preferred Hospital *

Name of Physician and Phone Number *

Name of Dentist and Phone Number *

Health Insurance Provider and Policy Information: *

Volunteer Opportunities

Additional Comments and Submit

Is there anything we should know that we did not ask? Do you have any additional comments? *

Thank you for submitting this registration form. Please take a moment to read through the form and ensure your answers are complete and accurate before submitting.

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Shepherd of the Hills Registration Form

Consent Form

Health Care Information

Volunteer Opportunities

Additional Comments and Submit

Shepherd of the Hills Lutheran Church

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