Youth Group Registration Form

Youth Group Registration Form [2023 – 2024]

We welcome your youth’s participation in the youth ministry program at St. James! Please complete the following information. If you have any questions, please contact the office at 717-334-2012, or Youth Minister, Adam Michael ([email protected]).

Youth Contact Information

First Name of child/youth

Last Name of child/youth

Grade

School Attending (Gettysburg Area School District); if other, please list below.

Indicate your school if not listed above.

T-shirt Size

Street Address

City

State

Zip

Youth cell phone (if applicable)

Youth email (if applicable)

Parent/Guardian Information

Mother/Guardian’s name

Email Address

Home phone

Cell phone

Father/Guardian’s name

Email Address

Home phone

Cell phone

Transportation

If your child will come directly to Youth Group after school, please complete a Permission Slip instructing the school to allow St. James Lutheran Church volunteers to pick-up your child or to allow them to ride the bus to St. James Lutheran Church in Gettysburg.

Who will typically pick-up your child after Youth Group events & activities?

Is there anyone who should NOT be allowed to pick-up your child?

Is there anything else the church should know about your child’s schedule that might conflict with regularly scheduled Youth Group? (i.e. special pick-up times, known dates of absence)

Health & Wellness

Current Medications

Allergies

Known medical conditions and drug reactions

In the event that my child becomes ill or is injured, I authorize the adults in charge to take the following steps:

1) Call the parents/guardians. If unavailable, the person below should be called to act on my/our behalf.

Emergency Contact (other than parent/guardian)

Emergency Contact Relationship

Home Phone

Cell Phone

Additional details/contact info.

2) If the provided emergency contact cannot be reached, I authorize the adult volunteers to use their discretion in securing medical attention and treatment for my child.

Medical Attention

Yes

Preferred Hospital/Pediatrian

Insurance Company

Policy Number

Group Number

I give my permission to the church staff or adult volunteers to seek/administer First Aid in case of a minor medical situation. In the event of an emergency where medical treatment is required, I give my permission to the church staff or adult volunteer to obtain the services of a licensed physician. Please notify me immediately concerning any such emergency. I understand that I am responsible for all costs incurred for such treatment.

Medical Attention/First Aid Permission

Yes, I give permission for medical attention /First Aid to be administered to my child

No, I do not give permission for medical attention/First Aid to be administered to my child

Photo Release/Media Permission

St. James uses a number of tools to publicize activities to the congregation and community.
Please read the media release statement and check one of the options below:

I, parent/guardian, give St. James Lutheran Church the absolute right and permission to use the likeness or image of my child in photography or videography that may result in publicity efforts seen by the public. I understand that photography or videography may be used in publications, media release, electronic media or other forms of promotion. I release St. James Lutheran Church, its offices, employees, council, pastors, photographers and designees from liability for any violation of personal or proprietary right I may have in connection with use.

Photo Release

Yes, I give permission for my child’s photo to be included in various media presentations

No, I do not give permission for my child’s photo to be included in various media presentations

I give my permission for my child(ren), to participate in Youth Group events, choir, and Christian Education activities at St. James Lutheran Church.

You will be asked to sign a printed summary of this registration form and agreement at your child’s first Youth event, verifying/formally authorizing the submitted information on file with the Youth Minister and Church Office.

If you have any questions or concerns, you are welcome to speak with a member of the church staff by calling 717-334-2012.

Please complete this form for each child in your household that will participate in youth activities and events.