Student Information
Student's Name: *
Student's Name:
Returning Student or New Student: *
Gender: *
Birthdate: *
Birthdate:
Baptized: *
First Communion Class taken at Peace: *
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.
Parent's Information
Parent 1: *
Parent 1:
Street Address:
City, State, Zip Code:
Parent 1 Phone: *
Parent 1 Phone:
Parent 2:
Parent 2:
Street Address:
City, State, Zip Code
Phone 2:
Phone 2:
Emergency Contact:
Emergency Contact:
Emergency Phone Number:
Emergency Phone Number:
Name of Insurance Company
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 2019-2020 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 Bryan Willkom/ Kristin Brantner/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. *
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 2019-2020 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 Bryan Willkom/ Kristin Brantner/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.
Registration Fee Options: *
Please check the Registration box and any other needs. You can pay online below, or drop a check off in the office at Peace.

Complete Payment Online