B.L.A.S.T Wednesday Night Education Preschool-9th Grade
Grace Lutheran Church
4:45-6:15 Open Door Meal
5:40-6:30 Preschool-6th Grade Education Time
6:35 Worship
6:35-7:40 - 7th-9th Grade Confirmation
300 S Grant St
Fairmont MN 56031
507-238-4418
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Student’s Name *
Student’s Birthday *
Grade in the Fall 2021 *
Required
Address *
City, State Zip Code *
Student's E-mail
Student's Cell Phone Number *
Parent/Guardian's #1 Name *
Parent/Guardian's address (if different from child)
Parent/Guardian's #1 City, State Zip Code (if different from child) *
Parent/Guardian's #1 Phone Number *
Parent/Guardian's #1 E-mail *
Parent/Guardian's #2 Name
Parent/Guardian's #2 Address (if different from child's)
Parent/Guardian's #2 City, State Zip Code (if different from child) *
Parent/Guardian's #2 Phone Number
Parent/Guardian's #2 E-mail
Emergency Contact *
Emergency Contact's Phone Number *
7th-9th Graders only... Who is your proposed confirmation Mentor?
Where would you be willing to serve this year at Grace? Looking to have 4 team teachers per grade, so you can rotate every other week, month or whatever works for your group. *
Please share medical conditions including allergies, vision/hearing concerns, physical limitations, learning disabilities, or other special concerns etc. *
If my child needs medical treatment while participating, it is my wish that treatment be started while efforts are being made to contact me. I consent to medical procedures deemed necessary by the physician while efforts are continued to contact me. I accept responsibility for all cost related to such emergency treatment. *
My child has permission to take part in all congregational activities, including off-site activities. *
I give my permission to use pictures and the name of my child in publications from Grace Lutheran Church, which may include: bulletin boards, Ways of Grace, Grace website or local newspaper. *
By checking this box and typing your name in below, you are stating that you are authorized to make decisions for the child listed above. Your digital signature on this form will be treated as a written one. Thank You. * *
Type in your Full Name and Date. Thank You! *
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