CHILDREN/YOUTH MINISTRY Registration

Parent/Guardian (1) *
Cell Phone *

Area Code Phone Number
Email *
example@example.com
Would you be interested in joining a small group for parents?

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian (2) *
Cell Phone *

Area Code Phone Number
Email *
example@example.com
Address
*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How many children are you registering?
CHILD 1
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
School
CHILD 2
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
School
CHILD 3
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
School
CHILD 4
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
CHILD 5
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
School
CHILD 6
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
School
CHILD 7
Name *

First Name Middle Name Last Name
Preferred Name *
Birthdate *

Month Day Year
Date
Grade in School *
School
IN CASE OF EMERGENCY
Medical Insurance Provider *
Physician Information *
Physician's Name
Phone Number *

Area Code Phone Number
Health Concerns (Allerigies, Medications, etc.) *
In Case of Emergency *
Contact Person
Best Phone *

Area Code Phone Number
Please Select One: *

When a parent or guardian cannot be contacted, I authorize an agent of St. John's Lutheran Church (Teacher/Staff Member) to make arrangements for my child to receive medical/hospital care, to include necessary transportation, in accordance with their best judgement. I agree to pay all costs incurred as a result of the emergency which are not covered by my insurance. I do not agree with the above statement and leave the following alternative action in the event of an emergency:
Alternative Actions: *
CHILD SAFETY INFORMATION
Will the child(ren) be picked up by anyone other than the Parent/Guardian(s) listed above? *
I authorize the following people to pick up my child(ren):
*
Are there any individuals who are specifically not allowed to pick up the child(ren)?
The following person/people MAY NOT pick up my child(ren):
*
PUBLICITY STATEMENT

St. John's Lutheran Church takes photographs and records video footage during various church events for both archival and publicity reasons. These photos may be used in publications such as, but not limited to, the Spokesman, Weekly E-Blast, Departmental brochures, announcements, event advertisements and the website.
- Sunday School
- Vacation Bible School
- Come to Bethlehem
- Blessing of the Backpacks
- Sunday Worship, specifically on festival days
- The Crab Feed
- Santa Lucia
- Various other fundraisers and events
While we cannot monitor if a child is photographed or recorded, we can ensure that photos and videos of children are not published without their parent/guardian's permission.
PUBLICITY RELEASE
*
*

give St. John's Lutheran Church permission to publish photographs or video footage of the aforementioned minor in any of their various publications and communications. I will not seek compensation from or pursue legal action against St. John's Lutheran Church or its agents with respect to these photographs or video recordings. DO NOT give St. Johns' Lutheran Church permission to publish photographs or video footage of the aforementioned minor in any of their various publications and communications.
Agreement & Consent *

I understand that checking this box constitutes a legal signature cofirming that I acknowledge and agree with the above Terms of Acceptance.
*
ELECTRONIC SIGNATURE
Should be Empty: