Online Form Sunday School and Confirmation Registration Family Last Name:* Parent 1:* Parent 2: Child's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 1 Cell Number:Can we send a text to this number? Yes No Parent 1: Email address* Parent 2 Cell Number:Can we send a text to this number? Yes No Parent 2: Email address* Who does the child live with? If child lives in a separated family, who is the primary contact person? Are you a member of Ezekiel?* Yes No Interested in Membership? Yes No Child(ren) baptized? Yes No If no, interested in learning about baptism? Yes No Has your child(ren) had First Communion? Yes No EMERGENCY CONTACT 1: In the event a parent can't be reached in case of emergency, who else could we contact? (Name, Home Phone, Cell)* Child 1: First and Last name* Child 1: Date of Birth* Child 1: Gender Male Female Child 1: Age Child 1: Grade Child 1: School CHILD 1: Which program is he/she registering for?* Sunday School for Pre-K-5th Grade 6th Grade Confirmation 7th & 8th Grade Confirmation 9th Grade Confirmation Child 2: First and Last name Child 2: Date of Birth Child 2: Gender Male Female Child 2: Age Child 2: Grade Child 2: School CHILD 2: Which program is he/she registering for? Sunday School for Pre-K-5th Grade 6th Grade Confirmation 7th & 8th Grade Confirmation 9th Grade Confirmation Child 3 :First and Last name Child 3: Date of Birth Child 3: Gender Male Female Child 3: Age Child 3: Grade Child 3: School Child 3: Which program is he/she registering for? Sunday School for Pre-K-5th Grade 6th Grade Confirmation 7th & 8th Grade Confirmation 9th Grade Confirmation Child 4: First and Last name Child 4: Date of Birth Child 4: Gender Male Female Child 4: Age Child 4: Grade Child 4: School Child 4: Which program is he/she registering for? Sunday School for Pre-K-5th Grade 6th Grade Confirmation 7th & 8th Grade Confirmation 9th Grade Confirmation Child 5: First and Last name Child 5: Date of Birth Child 5: Gender Male Female Child 5: Age Child 5: Grade Child 5: School Child 5: Which program is he/she registering for? Sunday School for Pre-K-5th Grade 6th Grade Confirmation 7th & 8th Grade Confirmation 9th Grade Confirmation Child 6: First and Last name Child 6: Date of Birth Child 6: Gender Male Female Child 6: Age Child 6: Grade Child 6: School CHILD 6: Which program is he/she registering for? Sunday School for Pre-K-5th Grade 6th Grade Confirmation 7th & 8th Grade Confirmation 9th Grade Confirmation Child Concerns (For each child please indicate any health issues, allergies, medications, medical concerns, learning and/or behavioral concerns, or anything else we should be aware of.):Parent Agreement: If I am in attendance, I agree to be inlvolved actively in the supervision of all children. If I observe any unsafe or disrespectful behavior, I will take the time necessary to provide the needed guidance and adult supervision. My overall goal is the safety and Christian education of all children. I will keep this ministry in my prayers. I, the parent/guardian of the child(ren) listed above, hererby authorize a representative of Ezekiel Lutheran Church to authorize emergency healthcare for my child(ren) if necessary. I, hereby authorize the staff and/or volunteers of Ezekiel Lutheran Church Confirmation Programs to take my son/daughter on a field trip which is part of this education program. I hereby hold the staff and/or volunteers of Ezekiel Lutheran Church harmless for any injury or harm that my son/daughter may incur while participating in these programs, a related field trip, or service project of the said programs. Field Trips are always planned in advance and parents are given notice as to when they are happening. For off site activities without a parent present, there will be a healthcare form to complete. Note: Photos of activities and events are occasionally used for publication on our website, brochures, newsletters, etc. If you do not wish to have your child’s picture published, please email: mnorum@ezekiellutheran.org. PhoneThis field is for validation purposes and should be left unchanged.
