2025-26 Grace Youth Registration & Medical Release Form

Please complete this form once per student per school year.

Your name *

Email address *

Student's Personal Contact Information

Please complete the student's contact information below. Student's personal cell phone number is optional. Parent/guardian contact information is collected later on the form.

Student's Name *

Address *

Birthdate *

School *

Grade *

Phone number

Medical Concerns and/or Prescribed Medications

Photo Release *

Grace Evangelical Free Church has my permission to use my or my child's photograph publicly to promote Grace Youth Ministry. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Parent/Guardian 1 Contact Information

Name (First and Last) *

Phone number *

Is Parent/Guardian 1's address the same as the student's? *

Parent/Guardian 1's Email Address *

Grace Youth will use this address to communicate with you regarding Middle School and High School programs.

Parent/Guardian 2 Contact Information

Name (First and Last) *

Phone number *

Is Parent/Guardian 2's address the same as the student's? *

Parent/Guardian 2's Email Address *

Grace Youth will use this address to communicate with you regarding Middle School and High School programs.

Emergency Contact Information

Please list someone other than a parent/guardian.

Name (First and Last) *

Phone number *

What is the emergency contact's relationship to the student? *

Insurance Information

A representative of Grace Youth would use this information in the event of an emergency and the parent(s) are unavailable.

Insurance Company *

Policy Number *

Insurance Company Phone Number *

Name of Policy Holder *

Relationship of Policy Holder to Student *

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.