Bethlehem Lutheran Church (BLC)

Childrenís & Youth Ministry

Registration, Medical, & Consent Form

For the entire year of September 2014-September 2015

(For age 3-12th Graders - Please print and complete both sides)

 

REGISTRATION

 

1st Childís Full Name___________________________________________ Sex _____ Age_____ Grade ______

Date of Birth_____________ Date of Baptism______________ E-mail__________________________

2nd Childís Full Name___________________________________________ Sex _____ Age_____ Grade _____

Date of Birth_____________ Date of Baptism______________ E-mail__________________________

3rd Childís Full Name___________________________________________ Sex _____ Age_____ Grade _____

Date of Birth_____________ Date of Baptism______________ E-mail__________________________

Fatherís Name______________________________ Motherís Name _________________________________

Guardian (If not biological parent) ____________________________________________________________

Childís Mailing Address _____________________________________________________________________

Home # _______________________________ Work #(s) ________________________________________

Parentís Cell #(s) ________________________ Parentís E-mail ____________________________________

Is there anything the leaders and teachers should know about your child/children? ___________________

___________________________________________________________________

If BLC is not your home church, where do you attend? ____________________________________________

 

ATTENTION PARENTS:

Children and Youth Programs are available for your child because parents, like you, give love, time, and energy where you are able. Please consider the following areas to serve:

*I will teach one rotation of Sunday School. Yes

*I will help with Kidís Activity Ministry Program (KAMP), 4th - 6th Grade. Yes

*I will help in the Kitchen on Wednesdays. Cooking Team Desserts

*I will chaperone a youth event. Yes

*I will drive for a youth event. Yes

 

 

 

 

 

 

 

Bethlehem Lutheran Church (BLC) Childrenís and Youth Ministry Medical & Consent Form

September 2014-September 2015

 

MEDICAL

Insurance Carrier____________________________ Policy# _______________________________________

Physician Name __________________________________ Phone # _________________________________

Allergies (including bee stings, drug reactions, food, etc.) (Child 1, 2, or 3) ________________________________________

Current Medications (including dosage) (Child 1, 2, or 3) ________________________________________________

Illnesses or other medical information of which we should be informed ______________________________

__________________________________________________________________________________________

Date of last tetanus shot: CHILD 1 _________________ CHILD 2 _________________ CHILD 3 _________________

Does your child know how to swim? CHILD 1 ________ CHILD 2 ________ CHILD 3 ________

Any restrictions or concerns? _________________________________________________________________

Emergency Contact (other than parent or guardian) ________________________ Relationship to child _________

Home # ______________________ Cell #________________________ Work # _______________________

 

CONSENT

I, _______________________ parent/legal guardian of ___________________________ understand that in the event of an emergency, or if any medical, surgical, hospital care, treatment and procedures become necessary for my child while they are participating in childrenís ministry/youth ministry with BLC , every attempt will be made to contact me. If I am unavailable, I grant those in charge of the event my permission to authorize medical attention as recommended by a licensed physician. I waive my right of informed consent to such treatment. We agree to pay all medical costs involved in any such emergency treatment. We release and discharge the Church and/or its representatives involved in this event from any liability whatsoever in exercising this permission. This authorization is for ALL BLC childrenís ministry/youth ministry activities for the year September 1, 2014 through September 1, 2015.

 

Parent/Guardian Signature __________________________________ Date______________________

Travel Authorization

In the event of an off site activity, I give permission for my child to ride in the car/van of a responsible driver chosen by the staff members of BLC. My child will ride with a seat belt.

Parent/Guardian Signature __________________________________ Date______________________

Media Consent

I consent to the use of any photograph or videotape of my child taken during the year for use in future presentations at BLC or posted on the BLC website (names of children will never be mentioned on web).

Parent/Guardian Signature __________________________________ Date______________________

Please keep in mind that the reason we ask for all of this information is to keep your child safe while they are under the supervision of BLC and to be able to mail you necessary information about our ministry. Should there be any changes in your childís medical information that would affect his/her participation in youth activities, please let the office know! Thanks!