Youth Ministry Registration
for the 2022-2023 School Year
Youth Information
Following Section is about the student being registered.
Full Name
*
Legal First Name
Legal Last Name
Preferred Name/Nickname
*
What does the student want to be called?
Birthdate
*
/
Month
/
Day
Year
Age
*
As of September 1, 2022
School
*
What school does the student attend during the 2022-2023 school year?
Grade
*
As of September 1, 2022
Physical Address where the Student Lives
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address where the Student Receives their Mail
Street Address or PO Box
Street Address Line 2
City
State / Province
Postal / Zip Code
Back to Emergency Information
Go to Parent Information
Parent/Guardian Information
Following section is about the legal parent/guardian registering above youth.
Who does the student live with?
*
Mom
Dad
Step-Mom
Step-Dad
Foster Mom
Foster Dad
Aunt
Uncle
Grandma
Grandpa
Other
Parent/Guardian Name(s)
*
Parent/Guardian Email
*
example@example.com
Additional Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Can we text you at this number about youth ministry events?
*
Yes
No (if no, we will only use phone number for emergencies)
Additional Parent/Guardian Phone Number
Back to Student Information
Go to Emergency Information
Emergency & Medical Information
Emergency Contact
*
Who to contact if above parent/guardian is unavailable.
Emergency Contact Phone Number
*
Please enter a valid phone number.
Health Insurance
*
Company & Policy/Member Number
Allergies
*
Are there any medical conditions, physical limitations, dietary needs, or medications we should be aware of?
*
Back Parent/Guardian Information
Go to Parent Permissions
Parent Permissions
Following section provides permissions for youth to attend Bucklin Free Methodist Church Youth Ministry on-site events.
I give permission for above stated student to attend weekly youth group at Bucklin Free Methodist Church
*
Yes
No (by selecting no, student will not be allowed to attend youth group at Bucklin Free Methodist Church)
I give permission for Bucklin Free Methodist Church to take photos/videos of above stated student for the purpose of sharing on Bucklin Free Methodist Church website, social media, and print materials for the express purpose of promoting and sharing with the Bucklin Free Methodist Church community. Names, ages, and school will not be shared without further permissions.
*
Yes
No
I give permission for Bucklin Free Methodist Church staff and volunteers to administer first aid and in the event of a medical emergency to secure transport (either by car or ambulance) for the above stated student to the nearest hospital.
*
Yes
By providing my signature, I confirm I am the parent or legal guardian of the above stated student and confirm the above selected permissions.
*
Submit
Should be Empty: