Youth Permission Form

Fill out this form to register your child for Lafayette Community Church youth activity.

One form per child.

Let the little children come to me, and do not hinder them, for the kingdom of heaven belongs to such as these.

Matthew 19:14

Youth Event Registration

Parents Name(Required)

First Last

Phone(Required)

Email(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

In Case of Emergency (Name, Relationship, Phone Number)(Required)

Childs Name(Required)

Childs Birth Date and Age

Grade Child is Entering

INSURANCE COMPANY, GROUP AND POLICY NUMBERS:(Required)

CHRONIC ILLNESS AND/OR ALLERGIES:(Required)

CURRENT MEDICATIONS:(Required)

PHYSICIAN NAME and Phone Number:(Required)

Social Media:(Required)

Yes

Can Lafayette Community Church post images of your child on social media's such as Lafayettecommunitychurch.org?