2015-16 Children & Youth Program Registration/Consent Form

Please complete this 2015-16 Program Registration and Cosent Form for your child(ren).

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* 1. Name of Child(ren)

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

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* 2. School Grade (Fall of 2015)

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

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* 3. Birthday and Age

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

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* 4. Street Address, City, State, Zip

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* 5. Parent(s)/Guardian(s) Name and Email Address

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* 6. Parent(s)/Guardian(s) Home and Cell Phone

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* 7. Emergency Contact Name and Contact Number

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* 8. Name and Relationship of Adults Approved to Pick-Up your Child(ren)

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* 9. Ministry Participation at Salem (check all programs you're interested in)

Sunday School (3yr-12th Grade)

Children's Faith Milestones (Baptism, First Bible, First Communion, 3rd Grade Bible)

Children's Music Program (Special Performances, Music Camp, Musicals, Chimes)

Cornerstone (Wedneday Evening Meal, Fellowship, and Activities for All Ages)

Senior High Events and Activites (9th-12th Grade)

Middle School Events and Activities (7th-8th Grade)

Confirmation (Education for 7th-8th Grade Students)

Other (please specify)

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* 10. Medical or Behavioral Concerns (including allergies)

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

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* 11. Current Medications

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

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* 12. Parent/Guardian Consent (check all that apply)

Salem Lutheran Church may publish photos and videos taken of my child(ren) during church activities.

(7th-12th Grade Only) I give permission for my child(ren) to be contacted via cell phone, text, email, and Facebook. I will contact the Salem office if I also wish to be copied on any or all communication.

I will inform staff and volunteer leaders reagarding all allergies and/or medical concerns affecting my child(ren).

I give approved Salem leaders permission to transport my child(ren) to and from events. I understand all approved drivers will require children to be secured by seat belts and will use any child safety restraint system I provide.

I give permission for my child(ren) to fully participate in all programs, activities, and events sponsored by Salem Lutheran Church. I understand that all measures will be taken to contact me in the event of a medical emergency involving my child(ren). If I cannot be reached I give the Salem adult leadership the authority to make decisions in the best interest of my child(ren).

Question Title

* 1. Name of Child(ren)

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* 2. School Grade (Fall of 2015)

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* 3. Birthday and Age

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* 4. Street Address, City, State, Zip

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* 5. Parent(s)/Guardian(s) Name and Email Address

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* 6. Parent(s)/Guardian(s) Home and Cell Phone

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* 7. Emergency Contact Name and Contact Number

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* 8. Name and Relationship of Adults Approved to Pick-Up your Child(ren)

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* 9. Ministry Participation at Salem (check all programs you're interested in)

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* 10. Medical or Behavioral Concerns (including allergies)

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* 11. Current Medications

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* 12. Parent/Guardian Consent (check all that apply)

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* 13. Parent/Guardian Electronic Signature