Youth Registration

• • Student Name *
    
    First
    
    Last
• • Student Email
    
    
• • School Attending
    
    
• • Grade
    ...6th7th8th9th10th11th12th
    
• • Special Concerns
    
    
• • Second Student's Name
    
    First
    
    Last
• • Student Email
    
    
• • School Attending
    
    
• • Grade
    ...6th7th8th9th10th11th12th
    
• • Special Concerns
    
    
• • Third Student's Name
    
    First
    
    Last
• • Student Email
    
    
• • School Attending
    
    
• • Grade
    ...6th7th8th9th10th11th12th
    
• • Special Concerns
    
    
• • Parent Name(s) *
    
    
• • Parent Email(s) *
    
    
• • Address
    
    Street Address
    
    Other Address (optional)
    
    City
    ...AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory
    State/Province
    
    Zip/Postal Code
    
    Region (optional)
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    Country
• • Home Phone Number
    
    
• • Parent Cell
    
    
• • Are you currently receiving our weekly email?
    Yes
    No
    
• • Please send me information on the following programs:
    Middlers Youth Group
    Senior High Youth Group
    Servant Trips
    Youth Sundays
    

• • Photography Permission

    I, (parent or guardian) hereby grant Saint Luke’s Parish and its staff permission to use photographs of my child(ren), taken at Saint Luke’s events for the purpose of publicity and community life (i.e. brochures, newsletters, photo collages, Parish website, etc.) without names or location mentioned. In the event this decision changes, I will contact Winnie Smith to make my preference known. Winnie.smith@saintlukesdarien.org 203 655 1456 X 122
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