Children & Youth Registration – St. John’s Lutheran Church

Registration 2019-2020

1Parent/Guardians

2Children

3Medical

4Children

5Youth Ministry

Instructions

Please use the following forms to register your child(ren) for the 2018-2019 school year. Visitors/new members are invited to register at any time throughout the year.

Visit the Children page (Preschool to Grade 5) or Youth page (Grade 6 to 12) pages for more information on the programming.

We appreciate your timely response in submitting this form. You only need to fill out this form once per family.
Parent/Guardian 1
Name*
First Last
Address*
Street Address City State ZIP Code
Receive mailings at this address?*
- Yes
- No
Work Phone
Home Phone
Cell Phone*
Email*
Parent/Guardian 2
Name
First Last
Address
Street Address City State ZIP Code
Receive mailings at this address?
- Yes
- No
Work Phone
Home Phone
Cell Phone
Email

Medical & Emergency Information

Please provide emergency contact information and medical information pertinent to each of your children.
Emergency Contact 1 (In the case a parent cannot be reached.)
Contact Name*
Phone #1*
Phone #2
Emergency Contact 2 (In the case a parent or Emergency Contact #1 cannot be reached.)
Contact Name*
Phone #1*
Phone #2
Medical Information
Doctor's Name*
Doctor's Phone*
Dentist's Name*
Dentist's Phone*
Preferred Hospital*
Hospital's Phone
Insurance Information
This is required by hospitals.
Policy Holder's Name
Name of Insurance Co.
Policy/ID Number
Parent/Guardian Consent
I am the parent or legal guardian of the child(ren) listed on this form, and I am informed of the activities offered by St. John’s Lutheran Church. As parent or legal guardian of my child(ren), I hereby consent for my child(ren) to attend and participate in all activities provided by St. John’s Lutheran Church.
- I give permission for my child(ren) to participate fully in all activities sponsored by St. John’s Lutheran Church.
- In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give St. John’s permission to act in my behalf in seeking emergency treatment for my child(ren) in the event that such treatment is deemed necessary. I give permission to those administering emergency treatment to do so, using those measures deemed necessary. I understand that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child(ren).
- I give my consent to all forms of transportation (personal vehicles, rented vehicles, commercial buses). John’s is not responsible for transportation by non-St. John’s people.
- I give St. John’s permission to use my child(ren)’s picture for publicity. No personal information will be used.
Please type "NO" below if you do NOT give permission to use pictures for publicity
Parent/Guardian Signature*
By typing your name here this acts as your signature.
It is your responsibility to notify St. John‘s staff of any changes in information. (Policy changes, changes of health conditions, medications, address or phone changes.)

St. John’s Lutheran Church

Registration Form

Registration 2019-2020

Instructions

Parent/Guardian 1

Parent/Guardian 2

Basic & Contact Information

Child 1

Child 2

Child 3

Child 4

Child 5

Medical & Emergency Information

Emergency Contact 1 (In the case a parent cannot be reached.)

Emergency Contact 2 (In the case a parent or Emergency Contact #1 cannot be reached.)

Medical Information

Insurance Information

Parent/Guardian Consent

Programming for Pre-K Through Grade 5

Child 1

Child 2

Child 3

Child 4

Child 5

Programming for Grades 6 Through 12

Youth 1

Youth 2

Youth 3

Youth 4

Youth 5