Confirmation Registration Form
St. Peter's United Church of Christ
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Grade entering in fall
Please Select
PreK
K
1
2
3
4
5
6
7
8
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
If the above parent cannot be reached, please list an additional Emergency Contact
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health Insurance Company
Health Insurance Billing Address
Policy Number
Name of Insured
Name of Physician/Pediatrician
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last Tetanus shot
-
Month
-
Day
Year
Date
Any Allergies or Medical Conditions?
Yes
No
Please give details
Do you want to add something about your child?
I, undersigned, agree with the following statements:
*
In the event of an injury or illness, I give permission to the leaders to secure necessary medical treatment, and I relieve them of any and all liability in such event, understanding that I will be contacted promptly if such a situation arises. I understand that the church may record the image, voice, or likeness of the applicants. I hereby give permission for St. Peter’s United Church of Christ to use images in conjunction with publicizing events without remuneration to me or my child(ren). Personal information is not released in any publicity materials without the expressed consent of the parent. This form remains in effect from May 1, 2024 through September 1, 2025 or until revoked by the parent or guardian. It is the parent’s responsibility to inform St. Peter’s United Church of Christ of any changes or additions.
I, as parent/guardian of the child listed above, give my permission for him/her to accompany pastors, youth advisors, and/or recognized youth chaperones of St. Peter’s United Church of Christ on Church sponsored youth outings and activities. I understand there are dangers and risk of injury inherent in participating in these youth outings and activities, but still desire to allow the above named youth to participate in such activity. Therefore, the undersigned, for and in consideration of the opportunity to allow the youth to participate in youth outings and activities, and for other good and valuable consideration, does hereby forever release, quit and forever discharge St. Peter’s United Church of Christ, it pastors, youth advisors, employees, insurers, agents, servants, and recognized youth chaperones (hereafter referred to as “Released Parties”) from any and all claims, demands, rights and causes of action of any kind or arising out of any and all known and unknown, foreseen or unforeseen bodily and personal injuries, property damage or the consequence thereof, resulting from any accident, casualty or event involving the above named youthparticipant and arising out of participating in Church sponsored youth outings and activities.I UNDERSTAND THIS MEANS I AGREE NOT TO SUE ANY AND ALL OF THE RELEASED PARTIES FOR ANY INJURIES ORPROPERTY DAMAGE RESULTING TO THE ABOVE NAMED YOUTH PARTICIPANT DURING OR IN CONNECTION WITH HIS ORHER PARTICIPATION IN CHURCH SPONSORED YOUTH OUTINGS AND ACTIVITIES.I understand this Release does not waive liability for intentional reckless acts, as such claims cannot be waived, but dounderstand this Release waives claims of any other kind, specifically including claims for negligence, against the ReleasedParties.FURTHER AND BY WAY OF INDEMNITY, the undersigned hereby expressly understands and agrees to indemnify and holdharmless the Released Parties, their employees, agents, or insures, against any and all claims for damages, costs orexpenses, incurred by the Released Parties, their employees, agents or insures, as a result of any accident or injury whichmight occur while the above named youth participant is participating in Church sponsored youth outings and activitiesand which may result from the negligence of the Release Parties, their employees, and agents, third parties or anycombination thereof.The undersigned further declares and represents that no promise, inducement or agreement not contained in thiswritten agreement has been made to the undersigned and that this Release contains the entire agreement between theparties and the terms of the Release contractual and not mere recital. The undersigned further acknowledges theopportunity to negotiate this Release with an authorized member of St. Peter’s United Church of Christ.
I am interested in helping:
I am interested in helping with Confirmation
I am interested in serving on our Church's Christian Education Ministry Team
I am not able to help at this time
Date
-
Month
-
Day
Year
Date
Please type your name below, agreeing to the above paragraphs
*
First Name
Last Name
Save
Submit
Should be Empty: