Youth Ministries Registration Form

Please complete one form per student who plans to participate in activities and ministries at Salem Covenant Church. Paper copies of this form are available in the church office, if preferred.

We recognize the confidential nature of some of the information gathered on this secure form. Information on this form may be communicated with the appropriate staff and volunteers at Salem as deemed necessary. Salem’s staff and volunteers understand the importance of the need to keep this information confidential.

Today's Date	*
Student's Name	*
Gender	*	Male Female
Student's Birth Date (mm/dd/yyyy)	*
Grade Level	*
Parent/Guardian's Name(s)	*
Home Phone Number
Home Address	*
Cell or Work Phone Number
Parent's Email
Student's Email (grades 6-12)
Emergency Contact Name and Phone Number (other than parent/guardian)	*
Drug/Food Allergies or Medical Conditions
Anything you would like to share with us about your child to help us meet his/her needs:

Permissions and Authorizations
I give my son/daughter permission to be involved with the ministries at Salem and understand that the staff and volunteer workers will do their best to care for my child. In the event of an emergency, I authorize Salem Covenant Church to approve any immediate medical care for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment. For younger children, I also give the staff and volunteer workers permission to escort my child to the bathroom.
Please select yes or no:	*	Yes No

I give permission for Salem Covenant Church to photograph my child and used at Salem's discretion
Please select yes or no:	*	Yes No

Please check each activity or ministry that your child plans to participate in this year (hold Ctrl key to select multiple activities or ministries):	* Hold Ctrl key to select multiple activities or ministries.
Security Code	*