Youth Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Grade in Fall *

7th Grade

8th Grade

9th Grade

Student Cell Phone

(###)

###

####

Baptism Date

MM

DD

YYYY

Parent/Guardian 1

First Name

Last Name

Parent/Guardian 1 Cell Phone

(###)

###

####

Parent/Guardian 2

First Name

Last Name

Parent/Guardian 2 Cell Phone

(###)

###

####

Emergency Contact (other than parents)

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

I give my permission for my child to participate in these activities, which will be led by a Safe Haven trained adult *

Confirmation

Local trips in a church vehicle or personal vehicle driven by a Safe Haven trained adult, including Church on the Go! and Youth Events

Other activities held at the church, including Youth Events

I give my permission for staff and leadership to text my youth with reminders about events or program updates. *

Yes

No

I give my permission to Holy Spirit Lutheran Church to use photographs and videos of my child in public displays, media releases and social media. I understand these photographs will not be sold or used for commercial purposes. *

Yes

No