Family Information Form 2021-2022

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This form must be on file for each participant in Trinity's CYF Ministry and is valid September 2021-August 2022. Any changes to the information on this form should be relayed to Heather Day or Ashley Olson promptly. Thank you!

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Cell Phone

Primary Phone Number *

Parent 1 Cell

Parent 2 Cell

Other:

Primary Email Address *

Street Address *

City *

Eau Claire

Altoona

Chippewa Falls

Fall Creek

Elk Mound

Eleva

Other:

State *

Other:

Zip Code *

Secondary Address

Name, Street, City, State, Zip - Include secondary address if you would like mailings sent to this address as well (if Parent 2 has a different address and would also like to get mailings, for example)

Member of

Trinity Lutheran

Interested in membership at Trinity

Other:

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Emergency Contact Name *

(other than parents)

Emergency Contact Phone Number *

Medical Release *

I (We) understand that, in the event medical treatment and/or transportation is required, every effort will be made to contact me. However if, I/we cannot be reached, I/we give permission to the staff or sponsor at Trinity to secure services of a licensed physician and/or licensed paramedics to provide necessary care for my child/children's well being. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Media Waiver and Release *

I consent to my child being photographed, interviewed, and/or videotaped by representatives of Trinity Lutheran Church and/or media outlets (newspaper, T.V. stations, etc.) Trinity Lutheran Church uses photos of children in congregational publications to share information about Trinity. Any images obtained may be reproduced by Trinity and/or the public media for use in advertising, publicity, or educational activities. Trinity publications include but are not limited to: the website, advertisements, apps, annual reports, posters, banners, bulletins boards, and other public relations materials. I hereby waive any claims I may have, and release Trinity Lutheran and its employees from liability of claims arising out of such activities.

Yes, my child may be photographed, interviewed, or videotaped/recorded for media use.

No, my child may not be photographed, interviewed, or videotaped/recorded for media use.

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