Student Ministry Registration 2023

Please fill out this form and click submit for each of your children in 6th through 12th grade. (One form per child)

Student Info

Name

Address

Birthdate

Grade

Please select one option.

6th 7th 8th 9th 10th 11th 12th

School

Does your child have any medical concerns and/or allergies? Please describe or type "no."

Please describe anything else that would be helpful for us to know about your child so we can best minister to him/her.

Parent & Emergency Contact Info

Please provide names and contact information for parents and emergency contacts. These people will be the only ones authorized to pick up your child from Student Ministry events.

Parent/Guardian 1 Name

Parent/Guardian 1 Email

This address will receive a confirmation email

Parent/Guardian 1 Phone

Parent/Guardian 2 Name

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

Emergency Contact Name

Emergency Contact Email

Emergency Contact Phone

Parent Permissions

May we have your permission to email your child?

Please select one option.

Yes No

May we have your permission to call or text your child regarding ministry information or for connection purposes?

Please select one option.

Yes No

Do you consent to your child's photos being used in newsletters, promotional tools like brochures, social media, or other uses deemed appropriate by Neelsville Presbyterian Church?

Please select one option.

Yes No

I give permission for Neelsville staff and leaders to call emergency personnel and give appropriate treatment for my child in the event I cannot be reached during a medical emergency. I understand that I, the parent or guardian, have financial responsibilty and liability for my child's illness or injury incurred on site at Neelsville Presbyterian Church or at an event location.

Please select one option.

Agree

Student Contact Info

Please complete this section if you have given permission for Neelsville ministry leaders to contact your child.

Phone

Signature

Please type your first and last name as the person who completed this form. This serves as your digital signature.

Description

Please fill out this form and click submit for each of your children in 6th through 12th grade. (One form per child)

Student Ministry Registration 2023

Description

Please Fix the Following