Student Information Form

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Use this form to register for Confirmation or Youth Ministries at Gethsemane Lutheran Church!

Student's Name (First, Middle, Last): *

Nickname / Preferred Name: *

Student's Gender: *

Female

Male

Non-Binary

Prefer not to answer

Student's Pronouns: *

She/Her/Hers

He/Him/His

They/Them/Theirs

Other:

Home Address: *

Home Phone:

Parent / Guardian Names: *

Student's Birth Date: *

Student's Baptism Date:

Student's School / District: *

Grade This Fall (2022): *

6th

7th

8th

9th

10th

11th

12th

Primary / Preferred Contact (Name and Phone): *

Secondary Contact (Name and Phone):

Student's Cell Phone: *

Student's Email: *

Primary / Preferred Contact Email: *

Secondary Contact Email:

Other Email:

Emergency Contact (Name and Phone): *

Allergies (if none, enter "none"): *

Dietary Restrictions / Preferences (if none, enter "none"): *

Photography/Video Acknowledgement *

I grant Gethsemane Lutheran Church my permission to use photographs and/or video recordings or live streams of my child for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. It is understood that no royalty, fee, or other compensation shall become payable for use of the photo or video.

I do not grant permission for Gethsemane Lutheran Church to use photographs or video of my child.

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