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Redeemer Youth Registration and Permission Form
This authorization is valid from September 1, 2021 - August 31, 2022
Redeemer Lutheran Church, 1545 Chain Bridge Rd, McLean, VA 22101
Contact us at 703-356-3346
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* Indicates required question
Email
*
Your email
Youth Name
*
Your answer
Grade (please check only one)
*
Preschool - age 3
Preschool - age 4
Preschool - age 5
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Birth Date
*
MM
/
DD
/
YYYY
Parent Name(s)
*
Your answer
Address
*
Your answer
Phone Number(s)
*
Your answer
Allergies
*
No
Yes
Peanuts
Other:
If answered yes to allergies, please let us know what type:
Your answer
Dietary Restrictions
Vegetarian
Vegan
Gluten-free
Peanut Free
None
Other:
Clear selection
Emergency Contact (name, relationship, phone)
*
Same as above
If other please list name and number below
If not the same as above, Emergency Contact (name, relationship, phone)
Your answer
Permission to participate in youth activities: I hereby grant permission for my child to participate in Redeemer Youth Ministry activities under the supervision of adult chaperones. I understand my child may engage in physical activities with risk of injury.
*
Yes
No
Permission for Emergency Medical Treatment: In the event that I cannot give authorization in person, I hereby authorize an adult chaperone from Redeemer Lutheran Church to seek emergency medical treatment for my child.
*
Yes
No
Permission for Photography: I give permission for my child's picture to be placed on Redeemer's website & on social media.
*
Yes
No
Permission to text Reminders: I give permission to receive texts from Redeemer Lutheran Church.
*
Yes
No
What number should we text?
*
Your answer
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