Memorial Lutheran Church
 

  Student Ministries
  Registration 
  2015/2016
  School Year



 

STUDENT INFORMATION:
First Name:
 *
Middle Name:
 *
Last Name:
 *
Street:
 *
City:
 *
State:
 *
Postal Code:
 *
Telephone:
 
Cell Phone:
 
Age:
 *
Birth Date:
 *
Grade:
 *
School:
 *
Student's Email:
 *

MOTHERS INFORMATION
Mother's First Name:
 *
Mother's Last Name:
 *
Mother's Email:
 *
Mother's Work Phone:
 *
Mother's Cell Phone:
 *
Mother's Vocation/Employer:
 *

FATHERS INFORMATION
Father's First Name:
 *
Father's Last Name:
 *
Father's Email:
 *
Father's Work Phone:
 *
Father's Cell Phone:
 *
Father's Vocation/Employer:
 *

OTHER INFORMATION ABOUT YOUR CHILD
Please list any other important information about your student and your family that you feel we should know. (learning difficulties, behavioral issues, custody issues, etc.) All information is kept confidential and is for understanding situations and behaviors as they arise.
Additional Important Information:
 *


INSURANCE INFORMATION
Health Plan Carrier:
 *
Policy #:
 *
Policy Holder's Name:
 *


EMERGENCY CONTACT INFORMATION
Emergency Contact First Name:
 *
Emergency Contact Last Name:
 *
Relationship to Student:
 *
Emergency Contact Home Phone:
 *
Emergency Contact Cell Phone:
 *


STUDENTS MEDICAL INFORMATION
Please list medical conditions, allergies, etc:
 *
Please list required medications:
 *


PARENT CONSENT TO TREAT A MINOR
I, being the parent or legal guardian, do consent to any x-ray, anesthetic, medical, surgica, or dental diagnosis or treatment that may be deemed necessary for my minor child. Further, I understand that all efforts will be made to contact me prior to treatment. In the event I cannot be reached in an emergency, I give permission to the adult supervisor to make the decisions necessary for treatment. Should there be no adult spervisor available, I give permission to the attending physician to treat
Agree to "Parent Consent to Treat a Minor" Terms?:
 *


ACTIVITY PARTICIPATION AGREEMENTS:
I, being the parent or legal guardian, have been informed of the High School/Middle School Activities below. ("the activities") sponsored by Memorial Lutheran Church ("MLC") and hereby give my consent for my minor child to participate in the selected activities.

In consideration for the opportunity to participate in the activities, the Participant (parent/guardian if Participant is a minor) acknowledges and accepts risks of injury associated with participation in and transportation to and fr
I have read and understand the above Activity Participation Agreement:
 *
My child may participate in the Confirmation Retreat at Inspiration Hills, August 21
 
My child may participate in the Fall Middle School Retreat at Inspiration Hills, September 18-19:
 


EARLY RETURN CONSENT STATEMENT:
In the event that a student must return form an MLC sponsored event independently for reasons of health, accident, or failure to conform to rules established by the adult leaers, event supervisors, etc., the parent/guardian agrees to accept full responsibility for and to pay for the cost of medical care, transportation and other related incidental expenses.
Agree to "Early Return Consent Statement" Terms?:
 *


STUDENT AGREEMENT
I, the above named students, as a participant in student events sponsored my MLC, will listen to my adult leaders and event supervisors. I will abide by all guidelines especially instructions related to my safety and the safety of my fellow students. I understand that failure to follow the prescribed guidelines and/or safety procedures may result in my having to leave an MLC sponsored event early and at my parent/guardians expense. I have read the above paragraph and understand its significance.
Agree to "Student Agreement" Terms?:
 *
Verification Code:
Insert above code:
 * Required

Memorial Lutheran Church • Sioux Falls, SD • 605-334-7133  © 2017