P.R.A.Y. Religious Emblem Program

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Welcome to the PRAY Religious Emblem program! The St. Barnabas Youth Director will serve as the program Counselor for kids in 1st-8th grade who would like to complete the program. Simply complete this form to register. All are welcome!

Student's Name: *

Grade: *

Birth Date:

YYYY

Parents'/Guardians' Names: *

Email: *

Cell Phone Number (to which we can text updates/reminders): *

Secondary Cell Phone / Contact Number

Street Address: *

City, State and Zip Code *

Denomination / Religion

Current Membership (if any)

Girl Scouts of America

Boy Scouts of America

American Heritage Girls

None of the Above

Clear selection

Special needs, medical concerns/allergies, or any pertinent family information:

Are any of the adults in your family interested in being a co-leader for the duration of the program?

Yes

Maybe

Clear selection

Does St. Barnabas Lutheran Church have permission for your child's image/voice to appear in church written, video and online publications? *

Yes

Any additional comments?

In the event of illness or accident, if I cannot be reached, I authorize the church or its agents to consent to any diagnosis, exam, treatment, hospitalization or transportation deemed advisable for my student by and rendered under the supervision of a physician. I release the church and its agents from responsibility in case of accident or illness in connection with any church sponsored activity. *

By checking this box, I agree to the above Emergency Authorization

Required

I certify that all of the above information is correct to the best of my knowledge: *

Yes

Submit

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