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First Lutheran Youth Event Registration Form
Please provide all required information so we have what we need for your child to participate. 
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Youth Name *
Youth Address including City, State and Zip *
Youth Cell Number (if available) 
Youth Email (if available)
Grade *
Birth Date *
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DD
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School *
Parent Name
Parent Cell Phone *
Parent Email Address *
Parent Alternative Phone
Emergency Contact Name *
Emergency Contact Relationship
 *
Emergency Contact Cell
 *
Emergency Contact Alternative Phone
Medications
Medical Alerts, Allergies, etc.  *
Additional Information We Should Know
Insurance Carrier *
Insurance Policy # *
Insurance Group Number *

My child has permission to participate in any activity sponsored by First Lutheran Church of St. Joseph, MO for the 2023-2024 ministry year. In case of an emergency, the adult in charge has my permission to seek any medical attention necessary, or to administer over the counter medications as needed by my child.

Parent/Guardian Signature (type name below)
Date
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I hereby grant First Lutheran Church of St. Joseph, MO the right to make, use, and/or publish any and all videos, photos, media, audio, or other images of my minor child in which they may be included, now existing or hereafter made, in any case, with or without identifying (him/her) for editorial, advertising, news, social media, or any other purpose and in any manner and medium. I hereby release and agree to fully and unconditionally defend, indemnify, and hold harmless First Lutheran Church of St. Joseph, MO employees and volunteers from any claims, costs or expenses for property damages, personal injuries, or other damages that may arise out of my minor child’s participation. In addition, I understand there will be no financial or other remuneration for recording my minor child in photos, videos, audio, or other images for initial or subsequent use, transmission, or playback. 

Parent/Guardian Signature (type name below)
Date
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I hereby give permission for my minor child to be contacted through social media or other electronic communications. 

Modes of Communication we will be using:

Text Messages

Email

Cell Phone

Facebook (private First Lutheran Youth page, parents invited)

Parent/Guardian Signature (type name below)
Date
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