Children and Youth Ministry Signup Form

This form is for use by both Sunday School and Youth Ministry programs.  Use the form below to sign your children up for Sunday School or other Youth Ministry activities this year.

Child #1 Name

Birthdate

Child #1

Grade

Child #1

Child #2 Name

Birthdate

Child #2

Grade

Child #2

Child #3 Name

Birthday

Child #3

Grade

Child #3

Child #4 Name

Birthday

Child #4

Grade

Child #4

Parent or Guardian

Home email address

Work email

Home Address

Cell Phone Number

Home Phone Number

Work Phone Number

What is the best way to convey programming information to your family?

Additional Emergency Contact: Name

In an emergency, every reasonable effort will be made to reach parents of youth participants.

Relationship to participant

Daytime Phone

Evening Phone

Other Phone

Address

Who, besides parent, in authorized to pick up your child(ren) from any church activities?

Please include name and phone number

Health Information: Child #1 - Allergies/health concerns/needs

Leave blank if none. If you have needs, please indicated medications child can NOT take, special dietary needs, and medical history that should be noted

Interests, strengths, special learning needs, and concerns

Child #1

Health Information: Child #2 - Allergies/health concerns/needs

Leave blank if none. If you have needs, please indicated medications child can NOT take, special dietary needs, and medical history that should be noted

Interests, strengths, special learning needs, and concerns

Child #2

Health Information: Child #3 - Allergies/health concerns/needs

Leave blank if none. If you have needs, please indicated medications child can NOT take, special dietary needs, and medical history that should be noted

Interests, strengths, special learning needs, and concerns

Child #3

Health Information: Child #4 - Allergies/health concerns/needs

Leave blank if none. If you have needs, please indicated medications child can NOT take, special dietary needs, and medical history that should be noted

Interests, strengths, special learning needs, and concerns

Child #4

If you have a middle school or high school child, please provide health insurance information

Please include Insurance Company Name, Full Name of Insured Cardholder (generally parent), Birth Date of Insured Cardholder, Policy I.D. Number, Group I.D. Number, and Customer Service Phone Number on back of card

I authorize staff members of LSUMC to communicate by email and/or texting with my child or the child for whom I have legal guardianship.

I authorize staff members of LSUMC to communicate using Google Groups or Facebook with my child or the child for whom I have legal guardianship.

I authorize staff members of LSUMC to use photos, video and/or other likenesses of myself and/or my child or the child for whom I have legal guardianship for promotional materials regarding LSUMC programs, facilities, or services. Such images will not be sold to other parties. Promotional materials bearing these images may be distributed for free to the public and posted on the LSUMC website at lakestreetumc.org

I understand that my child/youth will be participating in a number of activities for the calendar year 2017-18, which carry with them a certain degree of risk. I consent for my chil/youth to participate in these activities.

List activity restrictions below