Youth Ministry Registration Form

Welcome! If you have a child or youth between PreK - 12th Grade that will be participating in the Youth and Family Ministry program at Holy Trinity Lutheran Church, please complete this form for each child.

Child's Name

Date of Birth

Address

Grade

Please select one option.

Pre-Kindergarten Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

School

Please select one option.

Noah's Ark Preschool Bryant Elementary Carver Elementary Eisenhower Elementary Fulton Elementary Hoover Elementary Irving Elementary Kennedy Elementary Lincoln Elementary Prescott Elementary Jefferson Middle School Roosevelt Middle School Washington Hempstead Senior High School Alta Vista Campus Other

Parent or Guardian Information

Parent/Guardian Name 1

This address will receive a confirmation email

Cell Phone

Parent/Guardian Name 2

Cell Phone

Emergency Contact

Emergency Contact Name:

Emergency Contact Phone #

Emergency Contact if parents cannot be reached:

Name #1

Relationship

Phone

Name #2

Relationship

Phone

Additional names of individuals who may pick up child from programs:

Medical Information

Medical Information:

Medical Conditions or Concerns:

Allergies

Medications:

Doctor Name:

Hospital Preference:

Permissions

PHOTOGRAPHY: I give permission for my child to be photographed for use by Holy Trinity Lutheran Church in publicity or advertisements, newspapers, the website, Facebook, Instagram, Twitter, and other media. Your child's photo may appear on bulletin boards or other spaces within the church building.

Please select all that apply.

YES, I give permission for my child's photgraph to be used. No, my child's photograph MAY NOT be used.

MAILING/TEXTS LIST: I give permission to be added to the Holy Trinity Lutheran Church mailing/text list. This includes periodic mailings including upcoming events, weekly e-news, updates, and more.

Please select one option.

Yes No thanks

By entering my name in the box below, I am providing my digital signature on this Youth Ministry Registration Form.

Electronic Signature

Youth Ministry Registration Form

Description

Please Fix the Following