Confirmation Registration Student's Name * First Name Last Name Returning Student or New Student * New Student Returning Student If you are a new student, please list your friend requests for small group Gender * Male Female Birthdate * MM DD YYYY 2024-2025 School Grade * 6th Grade 7th Grade 8th Grade School Attending Baptized * Yes No First Communion Class taken at Peace Yes No If a Communion class was taken at a different church If the student has taken a First Communion class at a different church, please list the name of the church and the approximate date it was taken. The Lutheran Church-Missouri Synod has some similar teachings to other denominations. Pastor David or Allie may want to talk to you to see if it qualifies as instruction here. Allergies/Important Medical Information Does the student have any learning difficulties or special accommodations that would help his or her learning environment and help the teaching teams to meet the needs of your student, (IEP, special testing situations, sensory issues, etc.). This information will stay confidential Parent Information Parent #1 Name * First Name Last Name Parent #1 Email * Address * Street Address Address * City and Zip Code Parent #1 Phone * (###) ### #### Parent #2 Name First Name Last Name Parent #2 Email Parent 2 Address Street Address Parent 2 Address City and Zip Code Parent 2 Phone (###) ### #### Emergency Contact * We would try parents first, please list another person to contact here First Name Last Name Relationship Emergency Contact Phone Number * (###) ### #### Medical Insurance Provider Name of Insurance Company Medical Insurance Policy/Group Number * Please list any group, policy, or id numbers Permission and Authorization * I grant permission for my child, a minor, to participate in all Peace Lutheran Church Youth Ministry activities that are held on or off site (examples: community service/mission projects, Feed My People, Action City, Fields of Faith, etc.) during the 2024-2025 program year. I understand that I have a duty to provide primary accident and medical insurance for my child. I assume all responsibility and liability for injury to my child. I release and forever discharge the Lutheran Church-Missouri Synod, Peace Lutheran Church and all of its agents, servants, counselors, successors and assigns, directors, trustees, officers, employees and other representatives from any and all damages and causes of action either at law or in equity which I may have as a result of my child's participation in, attendance at, and travel to and from Peace Activities. I further give Adult Leaders authority to act on my behalf in the event I am not able to be reached by the phone number below and my child requires medical attention. By typing my name, I give the above authorization First Name Last Name Thank you!
