Registration Form
Please complete the following questions so we can best communicate and serve you through Faith in Action: Confirming One's Faith this 2022-2023 year. A new form needs to be used for each participant in a family unit.

If you would like to volunteer with this program or have any questions, contact Zion's Director of Youth & Family Ministries: Brianna Iverson at (608) 865-0197 or YouthAndFamily.zion@gmail.com
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Child's Name *
Child's Date of Birth *
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DD
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Child's Age *
Fall 2023 Grade (6th-8th) *
Current Name of School (or Indicate Homeschooling) *
The Church I'm Connected to....
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Parent/Guardian Name *
Parent/Guardian Email *
Address *
Phone Number *
This number is a... *
Can you receive texts? *
Parent/Guardian Name
Address (if different than first parent/guardian address)
Phone Number
Email
This number is a...
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Indicate if another person(s) should receive weekly updates because they are a Faith Mentor for your child (like a grandparent or Godparent). Add name and contact information below: Email, Phone, Address & Relation to Child.
Has your child been Baptized? *
If your child has been baptized, what is their Baptismal Date and who are their Godparents?
In case of an Emergency I hereby give permission to the medical personnel selected by the church staff to order X-rays, perform routine tests, and treat my child, in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the church staff to hospitalize, secure proper treatment, and order injection and/ or anesthesia and/ or surgery for myself or my child named herein. Write your name and the date to testify as your signature. Note that we will make every effort to contact you first. *
I hereby give permission to Zion, French Creek & Living Hope Lutheran Churches to use my youth's picture for use in publicity. *
How would you like to receive the Lesson Summary each week?
I would be interested in supporting Faith in Action by...
Any Questions?
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