APC Confirmation Class Registration Form 2019-2020

STUDENT INFORMATION:

Name

Middle Name

Birthdate

Phone

Has this student been baptized?

Yes No

If yes, what was the name of the church?

If yes, what is the approximate date?

So that we can best serve your child, is there anything you want to share about your child? Please list any known conditions that we should be made aware of (i.e. Learning Disabilities, Allergies, Dietary Restrictions, Medications taken, Medical, Physical, Emotional, Behavioral, etc.)

PARENT INFORMATION:

Name (Parent #1)

Cell Phone #

This address will receive a confirmation email

Address

Name (Parent #2)

Cell Phone #

Address (if different)

Permission Information:

My child's Primary Doctor

Primary Doctor's phone number

Health Insurance Company

Policy #

- My child (listed above) has permission to participate in all activities on the Allentown Presbyterian Church campus, including off-campus events, such as mission nights, special events and retreats. I understand my child will be traveling, either by foot or vehicle, with a church-approved Shepard.

- I grant permission to the Allentown Presbyterian Church to take and publish photographs, video, voice recordings, or any other likeness of my child for use in materials, both print and digital, that may be presented in the public domain for the purpose of promoting APC's programs and ministries.

- In the event of a medical emergency, I understand that I will be contacted immediately to authorize care. If I cannot be reached, I authorize Crossroads Youth and Young Adult Ministry staff to approve care.

- I have reviewed the calendar and will be available to participate in Confirmation along with my child.

Parent/Guardian Signature*

Date

*By entering my name in the box above, I am providing my digital signature on this form.

Description

Please fill out this form and click submit.

APC Confirmation Class Registration Form 2019-2020

Description

Please Fix the Following