Grace Youth Registration Form
Please ensure that all necessary information is completed.
Student Information
Student Name
*
First Name
Last Name
Nickname/Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Prefer Not To Say
Age
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
School
*
Grade
*
Allergies
Other Health Concerns
Interested in (Please check all that apply)
Bible and Donuts
Living Our Faith
Movie Game Nights
Mission / Service Opportunities
Youth Lunches
Back
Next
Parent/Guardian Information
Please ensure that all necessary parental/guardian information is completed.
Parent Name
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Relationship To Student
*
Please Select
Mother
Father
Aunt
Uncle
Grandparent
Other
Additional Parent
Additional Parent Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Parent Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Parent Email
example@example.com
Relationship To Student - Additional Parent
Please Select
Mother
Father
Aunt
Uncle
Grandparent
Other
Back
Next
Emergency Contact Information
Please ensure that all necessary emergency contact information is completed.
Emergency Contact Name
*
First Name
Last Name
Relationship To Student
*
Please Select
Mother
Father
Aunt
Uncle
Grandparent
Other
Emergency Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Medical Information
Please ensure that all necessary medical information is completed
Allergies
Medications
Special Needs or Conditions
Back
Next
Consent
Please check all necessary consent fields.
By checking each statement below, I acknowledge the following:
Food Allergies
*
As part of the programming, my child may be exposed to or served snacks. I have accurately provided information regarding allergies and medical conditions and will update as necessary.
Photos
*
Photos of Grace Kids and Youth programs and activities may occasionally be taken as a part of sharing Grace's life and ministry together. These photos may be shared publicly during worship at Grace, in Grace's building, and through media such as Grace's bulletin, website, social media, and newsletter. Photos shared will be group photos only and names will not be shared.
Registration information is collected for church records, statistics, and pastoral care by authorized church leaders and staff. It will not be used for other purposes. I confirm the above is accurate and understand my family’s privacy will be protected.
*
Please provide your signature by holding down the mouse button and moving the cursor, or using your finger on a touchscreen device.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: