2022 - 2023 Youth Registration Form

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First Name *

Last Name *

Students Cell Phone (# if applicable)

Students Email Address (If applicable)

Please check all boxes that apply. *

I the parent/guardian have signed up for remind for this school year.

I the above named student has signed up for remind for this school year.

I the parent/guardian of the above named student understand that I am a crucial part of my childs faith formation and fully expect to particpate in that responsibility throughout this school year.

Required

What program/grade will your student be attending this fall. *

Sunday School (preschool-6)

iQuest (grade K-5)

Sowers (grade 6)

Confirmation (grade 7-9)

High School (grade 10-12)

Required

Grade *

Birth Date *

YYYY

Age *

Gender *

Male

Female

School District *

Paynesville

Eden Valley - Watkins

Other:

The above student is a PLC Member (it is not necessary to be a member to participate in any activities of PLC.) *

Yes

Required

The above student has been baptized. *

The above student is receiving communion *

Parent/Guardian Information

Parent/Guardian Name *

Address *

City *

State *

Zip Code

Home Phone *

Cell Phone (Parent/Guardian #1) *

Cell Phone (Parent/Guardian #2) *

Email *

I give the following people permission to pick up my child.

1. Name *

Phone *

2. Name

Phone

3. Name

Phone

Emergency Contact (When parent/guardians cannot be reached.)

1. Name *

Relationship to student *

Cell Phone *

Home Phone *

2. Name *

Relationship to student *

Cell Phone *

Home Phone (If applicable)

Medical Information

Family Physician *

Insurance Company *

Allergies, physical limitations, pre-existing conditions, current medications, or other pertinent information *

Consent/Medical, Picture & Transportation Release Information (Read all and check all appropriate boxes.) *

I am the parent/legal guardian of the above named student, and hereby grant my persmission for him/her to participate fully in Paynesville Lutheran Church youth related trips and activities. In the event of an emergency, and I cannot be reached, I give permission for the supervising PLC staff or adult leader to sign forms that would ensure the NECESSAY and IMMEDIATE treatment of the student. I give permission to those administering emergency treatment to do so using those measures deemed necessary. I further more absolve those acting on my behalf in this regard from liability as long as there is not gross negligence.

The students who are registered for youth activities will have their picture taken or videotaped over the course of the year. The pictures may be placed on the Paynesville Lutheran Church web site and/or on the Facebook page. By signing below, you are allowing your child to be photographed and/or videotaped.

I hereby give permission for the student listed above to be transported in church vehicles to participate in the church related activities of Paynesville Lutheran Church.

Required

Signature of Parent/Guardian (typing your name signifies signature.) *

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