2021-2022 Confirmation Registration ⛪

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Welcome to the St. Barnabas Lutheran Church Confirmation program. Please complete this form to register.

Student's Name *

Parent's Name(s) *

Street Address *

City, State and Zip Code *

Mother's Cell Phone #

Mother's Email Address

Father's Cell Phone #

Father's Email Address

Student's Cell Phone # (optional)

Student's Email Address (optional)

2021-2022 Grade Level *

7th Grade

8th Grade

9th Grade

School *

Emergency Contact Name (other than parent) & Relationship to Student (i.e., Jane Doe - Grandma) *

Emergency Contact Phone # *

Does your student have any allergies (food or otherwise) St. Barnabas should be aware of? If yes, please list below: *

Does your student have any special behavioral issues St. Barnabas needs to be aware of? If so, please explain. *

What do you hope your student gets out Confirmation? *

I give St. Barnabas Lutheran Church permission to use photos and videos of my student on church run social media pages. *

Yes

I certify that all this information is correct to the best of my knowledge. *

Yes

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

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