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*Parent/Guardian Name

*Address

*City

*Zip Code

Email Address

*Phone Number

Alternate Phone Number

Home Church


*Child 1

*Name

*Date of Birth

*Age

Grade Completed

Allergies / Medical Information

Special Need / Other Information:


Child 2

Name

Date of Birth

Age

Grade Completed

Allergies / Medical Information

Special Need / Other Information:


Child 3

Name

Date of Birth

Age

Grade Completed

Allergies / Medical Information

Special Need / Other Information:


Child 4

Name

Date of Birth

Age

Grade Completed

Allergies / Medical Information

Special Need / Other Information:


Two Emergency Contacts:

*Contact 1:

Name

Phone

*Contact 2:

Name

Phone

*Dismissal Information: Name(s) of person(s) who may pick up this child from this event:

Throughout the year we take great photographs of the kids, which sometimes appear in Sunday slideshows, our church news articles, on the internet, and in our fliers and advertisements. Can your child be photographed for these purposes?

(Due to the number of children attending our events we cannot allow children to be photographed for some purposes but not others.)

Anything else we should know about your child?