First Lutheran Church: Registration

On-Line Education Registration Form

To sign up, please fill in the following information. To pay, please click on the following link.
Pay online (click the donate button and fill out the appropriate information on the form)

Registration Option:

Participant's Name:
Father's Name:
Mother's Name:
Other Guardian:

Participant's Email:
Parent's Email:

Participant's Home Phone:
Participant's Cell Phone:
Father's Phone/Cell:
Mother's Phone/Cell:

Participant's Address:
City:
State: zip:

Father's Address:
City:
State: zip:

Mother's Address:
City:
State: zip:

Participant lives with:
Date of Birth:

Home Church:

Gender:

Grade 2009-2010:

Emergency Contact:
Emergency Contact relationship:
Emergency Contact phone/cell:

Family Physician:
Family Physician Phone:

Insurance Company:
Insurance Policy Number:

Last Tetanus Shot:

Health Concerns:

Special Needs/behavioral problems: (If your child has a special need it's very important for us to know so we can ensure your child has the best possible experience. Some examples of Special Needs are: ADD/ADHD, physical disabilities, Autism, Allergies, etc. Please let us know how we can help your child.)

Authorization to Consent to Treatment of a Minor
(must be filled out and signed by parent/guardian)

I, the undersigned parent or guardian of , a minor, release First Lutheran Church from any financial responsibility if an injury should happen during church activities, programming, retreats, or trips. I understand that every effort will be made to contact me if my child needs emergency medical or dental treatment. However, if medical or dental treatment is necessary and I am not attainable, I do hereby authorize First Lutheran Church of Fargo, ND or any of its leaders, pastors, or representatives, as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or specific supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I understand that my insurance has primary coverage and First Lutheran Church’s insurance is secondary.

Electronic Signature:

FLC Mission Statement: Our mission at First Lutheran Church is to bring people
into a relationship with Jesus Christ, and to help them grow in the Christian Faith.