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Child's Name
*
Parent / Guardian Name (s)
*
Address
*
- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
Home Phone
Work
Cell
Email Address
*
Persons (other than parents) authorized to pick up the children. List names below.
Does your child attend Sunday School?

YES
NO
If so where ?
Is your child visiting our church?

Yes
No
Who is he a guest of ?
Birth date
*
Last grade completed In school
*
Medical Information
*

Please list below any Allergies/Meds or Special Needs:
Emergency Contacts (other than listed above)
May we have permission to photograph your child ?
*

Yes
No
May we have permission to use your child's photograph for the purpose of promotion?
*
Yes
No
Signature of Parent or Guardian
*
Date
*