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*Parent/Guardian Name

*Address

*City

*Zip Code

Email Address

*Phone Number

Alternate Phone Number

Home Church

Number of children being enrolled


*Child 1

*Name

*Date of Birth

*Age

Grade Completed

Please list any allergy, medical, or special need information you feel we need to know


Child 2

Name

Date of Birth

Age

Grade Completed

Please list any allergy, medical, or special need information you feel we need to know


Child 3

Name

Date of Birth

Age

Grade Completed

Please list any allergy, medical, or special need information you feel we need to know


Child 4

Name

Date of Birth

Age

Grade Completed

Please list any allergy, medical, or special need information you feel we need to know


Child 5

Name

Date of Birth

Age

Grade Completed

Please list any allergy, medical, or special need information you feel we need to know


Child 6

Name

Date of Birth

Age

Grade Completed

Please list any allergy, medical, or special need information you feel we need to know


Two Additional Emergency Contacts (optional):

Contact 1:

Name

Phone

Contact 2:

Name

Phone

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

Can we take photos of your child and use them on our church photo stories and website/facebook?

(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/children?

LIABILITY RELEASE: Every activity sponsored by Mentor Baptist Church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By checking this box, the parent or legal guardian agrees not to hold this Church or its volunteers liable for damages, losses or injuries to the person or proper undersigned. The parent or legal guardian understands that he/she is signing for the minor listed on this form and the signature is both for medical and liability release.

Sign in the box below: