Confirmation Registration/Info Change Form:
 This information will be restricted to First Lutheran Church staff only, based on necessity for specific information. We will assume that this will remain your correct and current information unless we receive a notice of change. You can up-date/change any of your information at any time, by resubmitting this form with your new information. You must fill-in your confirmation student’s full name in order to send. Thank You!!!

Student's Information:

  
Student's First & Last Name:
Gender:
Home Church:
Grade in 2007-08:
Birth Date (  /  /  ):
Student's Aim Screen Name:
Student Lives With: (Check All that apply by holding down Ctrl key when selecting multiple choices)
Do You Intend To Be Confirmed At FLC?
Any Health Concerns Or Special Needs:
 (Please Explain)

Student's Interests:

  
(Check All that apply by holding down Ctrl key when selecting multiple choices)

Contact Information:

  
Mom's Name:
Dad's Name:
Other Guardian's Name:
Student's Address, City & Zip:
Mom's Address, City & Zip:
Dad's Address, City & Zip:
Student's Home Phone #:
Mom's Home Phone #:
Dad's Home Phone #:
Student's Cell Phone #:
Mom's Cell Phone #:
Dad's Cell Phone #:
Student's E-mail Address:
Mom's E-mail Address:
Dad's E-mail Address:

Parent Information:

  
Mom's Occupation:
Mom's Work Phone #:
Can FLC Call You At Work?
Dad's Occupation:
Dad's Work Phone #:
Can FLC Call You At Work?

Parent Help:

  
(Check All that apply by holding down Ctrl key when selecting multiple choices)

Emergency Contact Information:

  
Name of Contact (Other Than Parent):
Relationship to Student:
Home Phone #:
Cell Phone #:
Work Phone #:

Health Form Waiver:

  
Family Physician's Name (& office phone #):
Insurance Company:
Insurance Policy #:
Last Date of Tetanus Shot:
Any Medical or Behavioral Problems:

Authorization to Consent to Treatment of a Minor:
(Must be filled-out & signed by Parent/Guardian)

  
Minor's Full Name:
I, the undersigned parent or guardian of (fill in name at right), a minor, 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 counselors, 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.  
Parent/Guardian’s Electronic Signature:

 

 

[Click here for printable registration form]