2021-2022 Teen Education & Programming - Form

Section A: Family Contact Information

* Parent/Guardian #1 First Name

* Parent/Guardian #1 Last Name

* Parent/Guardian #1 Email

* Parent/Guardian #1 Phone Number

* Parent/Guardian #2 First Name

* Parent/Guardian #2 Last Name

* Parent/Guardian #2 Email

* Parent/Guardian #2 Phone Number

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

Section B: Teen Enrollment Information

* How many teens (8th - 12th grade) are you enrolling for 2021 - 2022?

Teen 1 Information

* Teen 1 First Name

* Teen 1 Last Name

* Teen 1 Birthdate

Student 1 Email (if applicable)

Teen 1 Phone (if applicable)

* Are you registering Teen 1 for Education, Programming or Both?

Student 1 Allergy/Medication Details

Teen 2 Information

Student 2 Email (if applicable)

* Teen 2 Last Name

* Teen 2 Birthdate

Student 2 Email (if applicable)

Teen 2 Phone (if applicable)

* Are you registering Teen 2 for Education, Programming or Both?

Student 2 Allergy/Medication Details

Teen 3 Information

* Teen 3 First Name

* Teen 3 Last Name

* Teen 3 Birthdate

* Student 3 Email (if applicable)

Teen 3 Phone (if applicable)

* Are you registering Teen 3 for Education, Programming or Both?

Student 3 Allergy/Medication Details

Teen 4 Information

* Teen 4 First Name

* Teen 4 Last Name

* Teen 4 Birthdate

* Teen 4 Email (if applicable)

Teen 4 Phone (if applicable)

* Are you registering Teen 4 for Education, Programming or Both?

Student 4 Allergy/Medication Details

Section C: Release Forms

* FIELD TRIP AUTHORIZATION: I hereby authorize my child/ren to participate in field trips and programs with his/her class. I agree to hold our congregation (including its board, officers, staff and volunteers) harmless from any and all claims that may arise out of his/her participation in school trips and programs. Note: Parents will receive advance notice about field trips held throughout the year.

Please Select OneYes, I agree.No, I do not agree

* EMERGENCY TREATMENT: In case of emergency, we hereby authorize (by our indication below) the Education Director, Youth Director, Administrator, or Teacher to call our physician or take our child/ren to the hospital to receive appropriate emergency treatment.

Please Select OneYes, I agree.No, I do not agree

* PHOTO/VIDEO RELEASE: I hereby give permission to use the name and likeness, including photographs/videos of the minor(s) named above, for publicity, promotion, news release, videos and web use of our congregation and our school. This permission might also apply to written compositions or visual art created by the minor if selected for such use.

Please Select OneYes, I agree.No, I do not agree

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