Grace Lutheran Youth Registration
Sign in to Google to save your progress. Learn more
CHECK ALL THAT APPLY
Student(s) Name
Age(s)
Grade(s)
Address  
City and zip
Birthdate(s)  
Baptized?
 Date  
  Place   
Parent/Guardian Name
Grace Member?   
Clear selection
Home/Cell #  
Work #   
Best time to reach you  
  E-mail  
Will you please commit to checking email weekly?  
Clear selection
2nd Parent/Guardian Name 
Grace Member?   
Clear selection
Home/Cell #  
Work #   
Best time to reach you  
  E-mail  
Will you please commit to checking email weekly?  
Clear selection
Additional addresses for mailing or emailing to non-custodial parent/guardian:   
Specific information that would assist us in working with your children:
Additional Student Information: 
Has your son/daughter(s) received Pre-Communion Instruction?
What school do your children attend?
Do Grace Lutheran Church screened leaders have permission to contact your children via electronic communication to invite or remind them of church activities or offer congratulations on their activities/special events? [Parents will be copied]
Clear selection
Does Grace Lutheran Church have permission for your child(s) name and/or photograph to appear in church written, video, and online publicity?
Clear selection
Names and numbers of people who have your permission to pick up student from Church activities.
I grant permission for my child(s) to participate in the Grace activities marked above.
Parent/Guardian Virtual Signature
Date
MM
/
DD
/
YYYY
Does the participant have any health conditions (i.e., allergies, chronic conditions, food allergies, etc.) that we should be aware of prior to medical treatment or offering snacks?
Clear selection
If yes please explain, include any medications:
Emergency Contact #1 & Phone Number
Emergency Contact #2 & Phone Number
Name of Physician & Phone Number
Health/Accident Insurance Carrier and Policy Number (Optional)
Since the law requires that parental permission be obtained for most medical procedures on minors, I wish to give permission for medical staff to perform such diagnostic, therapeutic, and surgical procedures as they deem necessary for the above minor. I understand that my consent will allow procedures to be promptly carried out so that no unnecessary delays will occur with treatment. No surgical procedures will be performed, except in extreme circumstances, without parents or guardians being contacted and fully informed and their verbal consent obtained.
Virtual Signature of Parent/Guardian
Date 
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Tyler's Workspace. Report Abuse
Google Forms