Confirmation Class Registration 2021-22

Name of Student

Email (parents email is fine)

This address will receive a confirmation email

Parent Cell Phone (text Reminders will be sent here-only add if you want texts)

Student Cell Phone (text reminders will be sent here, only add if you want texts)

Student Address

Baptism Date (if applicable)

Grade Entering in Fall of 2021

7th 8th

Emergency Contact Information

Emergency Contact (other than parent/guardian):

Relationship to Child:

Emergency Contact Cell Phone:

Emergency Contact Alternate Phone:

Medical Information

Medical Insurance Company:

Policy Holder's Name:

Policy/Certificate Number:

Physician Name:

Physician Phone:

Does your child have any allergies?

Yes No

If yes, please list and/or explain type of allergies and reaction:

Please list any medications being taken, medical problems, or other pertinent information including physical, mental, or psychological conditions that may require medication, treament or restrictions:

Authorization for Treatment: I hereby authorize the Hope Lutheran Church staff and volunteers to administer medications and first aid as deemed necessary as well as authorize the medical personnel selected by Hope Lutheran Church Staff to provide emergency medical care by medical staff to hospitalize, secure treatment for, order injection, anesthesia, blood transfusions, or surgery, and to release any records necessary for insurance purposes as well as provide or arrange necessary related transportation for the above named participant. This form may be photocopied.

I Agree I DO NOT Agree

Photo Release

Photo Image Release: As a participant in a Hope Lutheran Church event, I give permission and consent to allow photos, and videos, to be taken of the above mentioned individual during the VBS session. I further give consent that any such images or videos may be published in a variety of ways and used to illustrate and promote Hope Lutheran Church.

I Agree I DO NOT Agree

Questions

Any concerns, questions, suggestions or comments for this confirmation year?

Donation

We are upgrading ALL students to the 2017 edition of Luther's Small Catechism. The Catechism itself (the six chief parts and questions and answers written by Martin Luther to explain them) was not revised – only the supplementary material known as the Explanation, which includes additional questions and answers and supporting Bible verses and relating Scripture to important issues in today’s culture.
We are aware of financial hardship families may be experiencing so supplies are provided reguardless but we are seeking at $20 donation to cover the catechism and workbook binder.

Donation to cover Catechism & workbook

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Confirmation Class Registration 2021-22

Description

Please Fix the Following