| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Preferred Name for Name Tag: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| Primary Phone: |
(______)______-________ |
| Work Phone: |
(______)______-________ |
| Cell Phone: |
(______)______-________ |
| *Email: |
__________________________________ |
| *Birthday: |
__________________________________ |
| *Grade Completed: |
__________________________________ |
| If PreK, will this child be 5 before Aug. 15?: |
Yes
No (circle one) |
| Allergies, Medical, & Special Needs: |
|
| *Medical Release Statement: |
In case of emergency I hereby authorize a representative of Northside Baptist Church to give consent for any and all necessary medical care for my child while he/she is in the custody of Northside Baptist Church.
I do not authorize consent for medical care for my child. (circle one) |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| Authorized Pickup #3: |
__________________________________ |
| Authorized Pickup #4: |
__________________________________ |
| Do you attend Church?: |
Yes No (circle one) |
| If so, where?: |
__________________________________ |
| May we have permission to photograph your child?: |
Yes No (circle one) |
| May we have permission to use your child's photograph in church publications?: |
Yes No (circle one) |
| Comments: |
|
