CONFIRMAND INFORMATION & PERMISSION

CONFIRMAND INFORMATION & REGISTRATION
NAME (as it should appear on Confirmation Certificate),*
BIRTHDATE
Month / Day / Year*

MonthDayYear
Date
Age
Baptized? Yes/No
If Yes, When?
FULL ADDRESS*
HOME PHONE
STUDENT'S CELL PHONE
E MAIL
example@example.com
SCHOOL
GRADE
Special needs, medical conditions or allergies that we need to be aware of
HOBBIES or INTERESTS
PARENT(S) OR GUARDIAN(S),*
ADDRESS (if different from above)
MOM CELL PHONE
Phone Number
Please enter a valid phone number.
E MAIL
example@example.com
DAD CELL PHONE
Phone Number
Please enter a valid phone number.
E MAIL
example@example.com
Are Parents members of Chesterton United Methodist Church?

yesno
Matthew 28:20: "And remember, I am with you always, to the end of the age."

Covenant for Students and Parents:

STUDENT: I will attend the listed events. I will participate fully in the mentoring process. When I cannot attend, I will let Pastor Heather know. I will give myself to learn what it means for me to be a follower and servant of Jesus Christ as I live my life.
Signature*

Clear
PARENT: I will support my child in making this confirmation process a priority and seek to witness the love and encouragement of our Lord as my child learns and grows in the Christian faith.
Signature*

Clear
Student Permission to Travel and Activities
I parent name*, give permission for my child, student name* , to travel with Chesterton United Methodist church from September 1, 2022 through August 31, 2023.
I understand my child may be riding with a designated adult from the church.

I understand my child will be subject to the rules and regulations of the leadership of Chesterton UMC.

I understand that if my child violates any of those rules or regulations I will be responsible to retrieve and transport my child from their event.

I agree to hold blameless Chesterton United Methodist Church for injury resulting from an accident in transportation or while attending a church-sponsored event.

Should my child need medical attention while traveling to or from or participating in the retreat, I give permission for that treatment to be provided at the discretion of the leadership team from Chesterton United Methodist Church.
Parent Signature*

Clear
Student Signature*

Clear
Date

MonthDayYear
Date
Student Name*
Student Phone Number
Parent Name*
Parent Phone Number*
Insurance Provider
Group Number
Policy Holder
Insurance Services Phone Number (usually found on back of card)
Emergency Contact (other than parent):
Name*
Phone Number*
Known Allergies*
Medications Student will take while away from home
May we put your student's picture on Church Website & Social Media Pages?*

YesNo
Should be Empty:

CONFIRMAND INFORMATION & REGISTRATION

BIRTHDATE

MOM CELL PHONE

DAD CELL PHONE

Student Permission to Travel and Activities