2024-2025 Youth Ministry Registration, Medical Release, and Permission Form

Registration

Student Name

Student Age

Student Birthday (Month/Day/Year)

Student Year in School

Student Pronouns

Student Email

Student Address

Parent/Guardian One Name

Parent/Guardian One Phone Number

Parent/Guardian One Email

This address will receive a confirmation email

Parent/Guardian Two Name

Parent/Guardian Two Phone Number

Parent/Guardian Two Email

This address will receive a confirmation email

Non-Parent Emergency Contact Name

Non-Parent Emergency Contact Phone Number

Medical Insurance Company

Policy Number

Physician Name

Physician Office Phone Number

Medical History

Select the areas of concern for your student. If necessary, add more detailed information.

Is your student a

Good swimmer Fair swimmer Non-swimmer

Does your student have allergies?

Pollens Medications Food Insect Bites None

If yes, please describe:

Does your student have any of the following?

Asthma Epilepsy/Seizure Disorder Heart Issues Diabetes Physical Disability ADHD Social Emotional Disorders Other None

If yes, please describe

Date of Last Tetanus Shot

Does you student wear

Contacts Glasses None

Does your student have any social/emotional needs we need to be aware of? Please explain below.

Please list and explain any major illnesses your student experienced in the last year.

Should your student's activity be restricted for any reason? If yes, please explain below.

What medications does your student take?

Should the need arise, may adult leaders provide your student with Tylenol?

Yes No

Permissions for the Year

Please answer the following questions to grant general permissions for your student's time in Confirmation or FLY this year.

I give my student permission to participate in all Faith Lutheran Church youth ministry events during the 2024-2025 school year.

Yes No

I give Faith Lutheran Church and it's adult leaders permission transport my student to and from select youth ministry events.

Yes No

I understand that I may need to provude transportation for my student when required.

Yes No Option

I grant permission for photos of my student to appear in church publications such as the Dove newsletter, church website, Facebook, and Instagram.

Yes No

In the event of an emergency, I give Faith Lutheran Church permission to bring my student to the nearest hospital for treatment. I understand I will be notified immediately.

Yes No

I grant permission for my student to attend the Synod-Wide Youth Ministry Network Event (11/16).

Yes No

I grant permission for my student to attend the Winter Retreat at Camp Wonderland in Salem, WI over the weekend of January 17-19.

Yes No

I understand that at all events there are inherent risks and I will not hold Faith Lutheran Church or its adult leaders accountable if injury occurs.

Yes No

FLY Specific Event Permissions

FLY Students: I grant my student to participate in Slip N Slide Kickball happening at Faith Lutheran Church. Yes No

FLY Students: I grant permission for my student to attend off-site game nights at another parent's home and acknowledge that Kayla may not be present (10/16, 1/15, 4/9). Yes No

Student Conduct Agreement

Students who participate in Faith Lutheran Church's Youth Ministry are expected to abide by the following rules of conduct. Students who fail to comply with these expectations may be sent home at the Youth Leaders' discretion and their parents' expense.
No possession or use or alcohol, drugs, or tobacco.
No fighting, weapons, fireworks, lighters, or explosives.
No offensive clothing.
Students will sleep in the appropriate sleeping quarters according to their gender.
Participation with the group is expected.
Respect property.
Respect one another, staff, and adult leaders.
Respect and comply with event schedules.

Student Signature

I, the student, have read the rules of conduct, the above evaluation of my health, and permissions to participate in Youth Ministry activities. I agree to abibe by the stated personal limitations and rules of conduct.

Record your signature by typing your name below.

Date

Parent Signature

My student has my permission to attend all youth activities sponsored by Confirmation and FLY (Faith Lutheran Youth) from September 1, 2024 through September 1, 2025. By signing this form, I/we as parent(s)/guardian(s) agree to allow my/our child to participate in events held both on and off the campus of Faith Lutheran Church and to participate in overnight events; students will need to confirm they are attending said off-site events prior to the event.

This consent form gives Faith Lutheran Church permission to seek whatever medical attention is deemed necessary and releases the Church and its staff of any liability against personal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her/them to attend events being organized by Faith Lutheran Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she/they is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by a youth ministry staff member.

Record your signature by typing your name below.

Date

2024-2025 Youth Ministry Registration, Medical Release, and Permission Form

Description

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