Middle School Youth Registration
 2023-24
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Student Information
Please complete a registration form for each child
Youth Full Name *
Preferred name
If different from name above
Address *
Date of Birth *
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Grade *
Name of School *
Youth Email *
Youth Phone Number
Has youth been baptized? *
If yes, date and church
Has youth been confirmed? *
if yes, date and church
What is your home church (if not Aldersgate)?
Youth Medical Information
Food allergies? *
Enter "None" if no food allergies
Anything we need to know medically or otherwise *
asthma, diabetes, seizures, activity restrictions, etc. or enter "None"
Parent/Guardian Information
Name of parent/guardian filling out this form *
Phone number *
Parent Email *
Name of second parent/guardian
Phone number
Parent Email
Emergency Contact
NOTE:  Parents will always be contacted first!
In case of emergency when parents cannot be reached, please contact: *
Phone number *
Relationship to youth *
By signing below I agree that in the event that my child listed above suffers any illness or injury requiring hospitalization, medical treatment or medication, I hereby give my permission for any medical treatment which may be deemed necessary by medical personnel. *
Your full name
Today's Date *
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Photo Disclaimer
By registering my child with the Aldergate United Methodist Church Youth Ministry, I authorize that my child may be photographed and/or used in video, print, and web publications from the church.  Please note that names are not published with photos.  If I do not agree to this I must submit a written notice to the Pastor or Director of Youth Ministries. *
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