Confirmation/Pre-Confirmation Registration Form
Lutheran Church of St. Andrew Youth Ministries
Student Name
*
First Name
Last Name
Student Email Address
example@example.com
Student Phone/Text
Please enter a valid phone number.
Format: (000) 000-0000.
Student Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student School Grade in September 2025
*
Please Select
6th Grade
7th Grade
8th Grade
Student School Name
Has the Student Been Baptized?
*
Please Select
Yes
No
If Yes, on What Date Was the Student Baptized?
-
Month
-
Day
Year
Date
Has the Student Received First Communion?
*
Please Select
Yes
No
Parent/Guardian 1 Name
*
First Name
Last Name
Parent/Guardian 1 Email Address
*
example@example.com
Parent/Guardian 1 Phone/Text
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Street Address (If Different from Student)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 2 Name
First Name
Last Name
Parent/Guardian 2 Email Address
example@example.com
Parent/Guardian 2 Phone/Text
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Street Address (If Different from Student)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which Parent/Guardian Will Serve as the Student's Primary Contact Point?
*
Name of Any Person Authorized to Drop Off/Pick Up/Transport Student Other Than Parent/Guardian
Emergency Contact If Parent/Guardian Cannot Be Reached
*
First Name
Last Name
Emergency Contact Phone/Text
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Insured for Medical Insurance
*
First Name
Last Name
Relationship of Insured to Student
*
Medical Insurance Company Name
*
Medical Insurance Policy Number
*
Medical Insurance Group Number
List Any Necessary Medications for Student
List Any Allergies of Student
If Student Has Been Prescribed Epinephrine for Allergic Reactions, Please Check Selection Below
Please Select
Prefer Student Carry
Prefer Teacher Carry
List Any Dietary Needs or Concerns for Student
May We Administer Headache and Minor Pain Medication to Student Such as Aspirin, Ibuprofen (Advil/Motrin), Acetaminophen (Tylenol), or Naproxen Sodium (Aleve)?
*
Please Select
Yes
No
Physician Name
First Name
Last Name
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Does the Student Have an IEP or 504 Program at School?
Please Select
Yes
No
Does the Student Have Any Learning or Mental Health Issues About Which Teachers, Pastor, and Administrators Should Be Aware?
Do You Consent to the Student Being Driven to/from Confirmation Activities by a Teacher or Other Driver Designated by the Confirmation Team?
*
Please Select
Yes
No
Do You Consent to the Video and Audio Recording of the Student with Respect to Conducting a Church Service Led by the Confirmation Ministry for Streaming, Downloading, or Other Means Related to the Church Service?
*
Please Select
Yes
No
Do You Consent to the Student Receiving Email and/or SMS Text Messages from the Confirmation Ministry? Note: Message and Data Rates May Apply Depending on Your Plan and Carrier.
*
Please Select
Yes
No
Do You Consent to the Parent/Guardian Receiving Email and/or SMS Text Messages from the Confirmation Ministry? Note: Message and Data Rates May Apply Depending on Your Plan and Carrier.
*
Please Select
Yes
No
Is There Any Other Information You Would Like to Provide?
Submit
Should be Empty: