RALLY and RYOT Registration Form

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

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
Policy Number
Group Number
Family Doctor
Emergency Contact 1
Emergency Contact 2
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
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.