HOPE Lutheran Education Registration & Medical Release Form 2021-2022
Parents, please fill out the following form and submit.

We ask parents/caring adults to:
- keep this ministry in their prayers
- regularly check e-mail for updates
- encourage and support youth in full participation of both worship services and youth activities
- provide feedback on what works and what we're missing
- assist with teaching and leading activities when possible
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Child's Name *
Birth Date *
MM
/
DD
/
YYYY
School *
Grade *
Preferred Pronoun
Youth phone and / or e-mail (if applicable)
Parent/Adult Name 1 *
Cell Phone *
E-mail *
Address *
Parent/Adult 2 Name *
Cell Phone *
E-Mail *
Address (if different)
Which phone or e-mail is best for Wednesdays? *
Emergency Contact Name and Phone *
Please share any information about your child that will help leaders provide a safe, positive experience for your child including any allergies and current medications.
Photos of my child may be used for the church website, newsletters, brochures, etc.
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Program Authorization
I give the above mentioned child my permission to participate in the Education Program at HOPE Lutheran Church including any local travel to and from special events. I authorize the adult leaders to obtain emergency medical assistance for my child if necessary with the understanding that we as parents and/or the emergency contact will be informed as soon as possible. I agree to be liable for all costs incurred in connection with medical services needed and to not hold the staff or volunteers of HOPE Lutheran Church liable for any injury that my child may incur while participating in the program.
Parent/Adult Name and Date
By entering your initials in the box below, you are effectively providing your signature for program authorization. *
Submit
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