Christ the King Youth & Family Registration

1
Program RegistrationI am registering my child for the following program (NOTE: PROGRAM FEES CAN BE MADE BY CHECK AND RETURNED TO THE OFFICE)
6th/7th/8th Grade Confirmation (Cost: $60)
9th Grade Confirmation (Cost: $200 includes MEA Retreat)
2
Parent/Guardian Information
Parent/Guardian #1
Parent/Guardian #2
Primary Street Address
Primary City, State and Zip Code
Primary phone
Primary email
Emergency Contact
Emergency phone
3
Student Information
Name
Birth date
Please Select
Please Select
6th
7th
8th
9th
Student Grade in 2018/19
Student School
Please enter your phone
Please enter your email
Please Select
Please Select
Yes
No
Not Sure
Is student baptized?
Baptized date, if known
4
Which social media does the student use?
Facebook
Instagram
Twitter
Snapchat
Not on social media
Other
5
Health and Allergy InformationPlease include all necessary information regarding your child's health including but not limited to allergies, medications, special needs, and behavioral issues
Allergies, medication, and special needs
Student's Physician Clinic and Phone Number
Health Insurance Carrier
Health Insurance Group Number
Health Insurance Member Number
6
Medical Release of LiabilityI give my child permission to attend and be transported to and from all church-sponsored events during the 2018-2019 program year. I understand that in case of emergency, every effort will be made to contact parents/guardians or emergency contacts listed above. I give staff and leaders of CtK permission to work with qualified medical staff and services to provide ANY treatment deemed necessary by a physician. I hereby release Christ the King, staff, officers, leadership, employees, volunteers, and affiliated organizations from and against all liability resulting from your child's participation in this CtK event.
YESNO
7
Youth Covenant (Grades 6-12)In everything we do as a group from Christ the King, we have responsibilities. As youth of CtK, we represent our families, our church, and most importantly, God's good intention for the world. By clicking "yes" you agree: 1.) to respect the property of all facilities and personal property of others; 2.) to not use or possess drugs, alcohol, tobacco products, firearms or weapons of any kind; 3.) to respect the rights of all members of the group, to not harm anyone physically, emotionally, or spiritually; 4.) to respect and follow the requests of all adults and leaders; 5.) that behavior which breaks the covenant could result in potential discipline including being sent home
YESNO
8
Photo/Image ReleaseI give permission to CtK staff and leaders to use my child's photograph, image, and voice in future church publications, marketing, and on the church website, and social media. Clicking "no" means your child will not be photographed, video taped or voice recorded while participating in CtK events
YESNO
Should be Empty: