St.

Peter’s Youth Ministry

Enrollment Form 2009-2010

Family Last Name _________________________________________________

Parent/Guardian names ____________________________________________

Address _________________________________________________________

Home phone ____________________ Email _____________________________________

Mom: Cell # __________________ Work# _______________ Email _________________________

Dad: Cell # __________________ Work# _______________ Email _________________________

Please write the name of each child from your family who will be participating in Youth Ministry programs at St. Peter’s.

Allergies/
Student name Grade Date of birth Health concerns

Emergency Contact Information:

Physician Name: _______________________________________ Phone number: ________________________

Dentist Name: _________________________________________ Phone number: _______________________

Person to call other than parents:

Name: _____________________________________ Phone: _________________ Relationship: ___________________

I, ___________________________________, am the parent or legal guardian of the child(ren) listed on this form and I
have been informed of the activities offered by St. Peter’s Lutheran Church located at 418 East Sumner St. in the city of
Northfield, County of Rice and State of Minnesota. As parent or legal guardian of my child(ren), I consent for my child(ren)
to attend and participate in all on site activities provided by St. Peter’s Lutheran Church.

There are times when St. Peter’s may use pictures of children in the Sunday morning power point, The Parish Visitor, on
bulletin boards or occasionally in the Northfield News. Please note any areas you do NOT wish your child’s photo to be
used.
Please do NOT use my child’s photo in the following:

Power Point NO____ Parish Visitor NO____ St. Peter’s Website NO____
Bulletin board NO____ Northfield News NO____

Signature ______________________________________________________ Date: _____________________________

*Please remember to fill out both sides of this form

 St. Peter’s Youth Ministry
Enrollment Form 2009-2010

Medical Consent/Release Form

I, ___________________________________, am the parent or legal guardian of the child(ren) listed on this enrollment
form. In consideration of the opportunity for my young person to participate and fully recognizing that such an undertaking
involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release,
absolve, indemnify and agree to hold harmless St. Peter’s Lutheran Church of Northfield, Minnesota, it’s agents,
employees, adult volunteers, leaders, organizers, sponsors and persons transporting our young person to, from and
during this activity. Neither St. Peter’s Lutheran Church of Northfield, Minnesota nor any of said persons shall be held
financially responsible for any injury, illness or death incurred as a direct result of these activities. In the event of an
emergency and I cannot be reached, I hereby authorize that emergency treatment (including but not limited to X-ray,
examination, anesthetic, medical or surgical diagnosis or treatment and hospital or clinic care) may be administered. I
further agree to pay all charges for dental, medical or hospital care or treatment.

POLICY ON BEHAVIOR: St. Peter’s Lutheran Church of Northfield, Minnesota holds a policy that all youth events will be
drug and alcohol free. If a youth is found in possession of and/or having consumed alcohol, illegal drugs or tobacco, the
parent(s) and/or guardian(s) will be notified immediately to come and take their young person home at their own cost with
no refunds. Any youth who engages in any behavior that is determined to be seriously disruptive will also be sent home
at their own cost with no refunds.

Parent/Guardian Signature: __________________________________________ Date: ___________________________

Participant(s) Signature:_____________________________________________ Date: ___________________________

______________________________________________Date: __________________________

______________________________________________Date: __________________________

*Please remember to fill out both sides of this form