St Mark's UMC Children, Youth & Family Registration 2024-2025

St Mark's UMC

Children, Youth & Family Registration 2024-2025
Children, Youth & Family Registration 2024-2025 (For Pre-K thru 12th Grade Youth)

Fill out one per child in your household. You will need your insurance card, phone numbers, and emails. The form cannot be "saved", plan for 13-20 mins to complete the form! Below you will find the simple online form to fill out to register your child for the Children, Youth & Family Ministry. One form for all ministries regarding Children, Youth & Families! Follow the steps below and you'll receive a response from St Mark's UMC that you have been registered! If you have any questions, feel free to contact Deidra Benser in the church office via email deidra@stmarksumccr.com. Parents and legal guardians of minor children are asked to complete this form. The information requested is designed to assist the church in providing for the safety of minors during church-sponsored activities.
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What grade will your child be in for the 2024-2025 school year?*
Please upload a profile picture of the child*

Cancelof
Student's Cell Phone Number (Youth)
(Only for Deidra to share events & connect with youth)
Student's Email (Youth)
(Only for Deidra to share events & connect with youth)
Parent/Guardian Name*

First NameLast Name
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Second Name (optional- If separated or divorced)

First NameLast Name
Second Address (optional- If separated or divorced)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Child & Youth Safety- Please Read

You will confirm the policy below on each individual child you register, we just ask you to read through it before registering and check the box on the individual registrations that follow.

Medical Treatment Authorization

I understand that reasonable attempts to notify me will be made in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of 911 and the providing of necessary medical services in the event my child is injured or becomes ill.

I authorize Pastor Bonnie Koeppen and Deidra Benser, and any adult supervisor, to make emergency medical decisions on behalf of my child if such decisions are required by law or deemed necessary or advisable by a health care provider. I understand that the Church and the persons named above will not be responsible for medical expenses incurred solely on the basis of this authorization.

I agree to notify the Church in the event of any health changes which would restrict my child’s participation in any normal youth or children’s activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.

Consent and Certification

I, the undersigned, being the parent or legal guardian of the child named above (the “child”), do hereby consent to the participation of my child in all of the regularly-scheduled activities of Children, Youth & Family Ministries for children of St Mark's UMC, Cedar Rapids, Iowa, (“Church”) for the period September 1, 2024 through September 1, 2025.

A copy/online version of this form shall be deemed to be as effective as the original.

Consent of Photos or Videos

I, the undersigned, being the parent or legal guardian of the child named above (the "child"), do hearby give permission to St Mark's UMC of Cedar Rapids, IA to take pictures and/or video of my child during Children, Youth & Family Ministry events. These pictures or videos may be used for promotional purposes which may include posting on St Mark UMC’s website, Facebook page, or Twitter. Please note: Children will not be identified by name, and no photos will be posted of children in vulnerable poses.
I, undersigned, agree with the following statements:*

Yes, I understand & give consentNo, I don't give consent
Health Plan Carrier*
Policy Number*
Insurance Agent Phone Number*
Please enter a valid phone number.
Policy Holder's Name*
Preferred Medical Facility*
Name of Physician/Pediatrician*

First NameLast Name
Physician/Pediatrician Phone Number*
Please enter a valid phone number.
Any Allergies or Medical Conditions?*

YesNo
Please give details of allergies, medical conditions, or taking any medications (describe & list)
Signature*

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St Mark's UMC

Children, Youth & Family Registration 2024-2025 (For Pre-K thru 12th Grade Youth)