Confirmation 2025-26

Youth 6-12th grade are invited to participate in Confirmation. Contact Pastor Wendy with questions.

Name of Parent/Guardian #1

This address will receive a confirmation email

Phone

Address

Name of Parent/Guardian #2

Phone

This address will receive a confirmation email

Confirmation Student

Student's name Name

Student's Date of Birth

Student's Grade for 25/26 School Year

Has the student been Baptized?

Yes No Unsure

If baptized, please share baptism date and church in which student was baptized.

Confirmation Student 2

Student's Name

Student's Date of Birth

Student's Grade for 25/26 School Year

Has the student been baptized? Yes No Unsure

If baptized, please share baptism date and church in which student was baptized.

Emergency contact

In the event of an emergency all efforts will be made to contact the parent/guardian of the student. In the event the parent/guardian cannot be contacted, the following person(s) will be contacted.

Name of Non-Parent/Guardian Emergency Contact #1

Phone number of Non-Parent/Guardian Emergency Contact #1

Name of Non-Parent/Guardian Emergency Contact #2

Phone number of Non-Parent/Guardian Emergency Contact #2

Family doctor name and phone number

Health insurance company

Health insurance policy number

Consent

Please provide your electronic signature to indicate your agreement with the following statements.

I have legal custody of the student(s) named, a minor, and am giving my consent for him/her to attend events organized by Polk City UMC. I understand there are risks involved in any event and I hereby release Polk City UMC, its pastor, employees, and volunteers from any and all liability for any injury, loss, or damage to a person or property during the course of my child's involvement with the organization. (Type electronic signature indicating agreement.)

In the event my child is injured and requires medical attention, I hereby give consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event that treatment is required from licensed physician or hospital personnel, I agree to hold such person free and harmless of any claims of responsibility for the cost of any medical care not reimbursed by my insurance provider. (Type electronic signature indicating agreement.)

Occasionally the church takes photos and videos during events for use on official church social media account, newsletters, and/or website. Please check the box indicating your consent to have your child's photo posted on these official platforms only.

Yes No

Description

Please fill out this form and click submit.

Confirmation 2025-26

Description

Please Fix the Following