Middle School Ministry

Student Information

First Name *

Middle Name *

Last Name *

Gender *

Date of Birth *

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip Code *

Email Address *

Mobile Number *

Phone Number *

School Grade *

Special Needs / Allergies

Parent(s)/Caretaker Information

Preferred Name *

Cell Phone *

Marital Status

Email *

Preffered Name

Cell Phone

Marital Status

Permission to Treat & Liability Release

I (we), the parent(s) or legal guardian(s) of the above listed child give permission for our child to attend and participate in programs at Bethlehem Lutheran Church and receive medical treatment if necessary; every effort will be made to contact me in an emergency. However, if I (we) cannot be reached, I (we) give my (our) permission to the staff to secure the services of a licensed physician to provide necessary care, including anesthesia, for my child's well being. I (we) also release and agree to hold harmless Bethlehem Lutheran Church and all its participants from any and all liability, I (we) assume all risk of injury, damage or expense as the result of participation in activities.

Please check one

Yes

Image Release

Please indicate here whether we have permission to use your image or your child's image in marketing or promotional materials for Bethlehem Lutheran Church. This includes both photographic and video images.

Please Check One

Yes