BLC Sunday School Registration and Event Participation Consent Form
This form is for BLC Child, Youth, and Adult 2018-2019 Sunday School Registration and will also serve as the  Participation Form for BLC Onsite Events.

Parents / Guardians: Please complete one form for each child separately. The Personal Information section for Parents / Guardians only needs to be completed once per family.

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Personal Information
Participant's Full Name: *
Prefers: (nickname, etc)
School Student Attends:
Current Grade:
Birth Date:
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Baptism Date (if known):
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T-shirt Size
Clear selection
Mailing Address *
Youth Email (if applicable):
Youth Cell (if applicable)
Mother/Guardian's Name:
Mother/Guardian's Home Phone:
Mother/Guardian's Cell Phone:
Father/Guardian's Name:
Father/Guardian's Home Phone:
Father/Guardian's Cell Phone:
Preferred email for family communication:   *
Preferred phone for family communication:   *
What else would you like us to know about your child?
BLC plans to provide Bibles for all children enrolled in Sunday School, as needed. Please indicate whether this child needs one of the Bibles below.  
Clear selection
How might you be willing to help with BLC Sunday School this year? (please select all that apply)
Authorization for Participation of Child or Youth  
I give permission for my child to participate in youth and family ministry activities sponsored by Bethlehem Lutheran Church in Fairport, NY during the 2018-2019 program year.
Parent Name:
Date:
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Medical Information
Does your child / youth (or do you) have any allergies or medical conditions of which we should be aware? *
Explanation of allergies and/or medical conditions
Does your child / youth (or do you) take any prescription medication(s)? *
Explanation of prescription medications
Does your child / youth (or do you) have any diagnoses or history of behavioral or learning concerns about which we should be informed? *
Explanation of behavioral or learning concerns
Date of most recent tetanus shot:
Health Insurance Company:
Company's Phone Number:
Policy Number: (If possible, please attach a copy of insurance card.)
Name of Policy Owner:
In case of an emergency, contact this person if parent / guardian cannot be reached. Name:
Relationship of emergency contact to student:
Cell phone for emergency contact:
Medical and Liability Release of a Minor or Self:
I, the individual or parent(s)/guardian(s) of the child named above, by signing this form agree that if immediate care is deemed necessary, and I was not able to be contacted, I (we) give the chaperones the authority to act in my (our) absence. I hereby agree to indemnify and hold harmless from any expense or claims of any nature Bethlehem Lutheran Church in Fairport, NY and its representatives. I understand that I am responsible for any charges that may be incurred.
Parent/Legal Guardian Name:
Date
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Media Release:
I, the individual or parent(s)/guardian(s) of the child named above give permission to use, publish, or disclose newsletters, brochures, periodicals, posters, websites, or other media related vehicles, any photographs, videos, audios, and any other material in which I or my child / youth may have appeared, spoken, written, or otherwise been represented. I understand that a copy of this release will be kept on file to indemnify Bethlehem Lutheran Church in Fairport, NY against any of the church's use of the materials indicated.
Name of Participant (or Parent/Legal Guardian if participant is under 18)
Date
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