Child's Name

First Name

Last Name

Child's Gender

Child's Age

Date of Birth

Last Grade Completed

What is the last grade your child has completed?

Parent / Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

Cell Phone

Email Address

Home Church

What church do you and/or your child currently attend?

Incase of Emergency Contact

First Name

Last Name

Relationship to Child

Emergency Contacts Phone Number

Child's Allergies or Other Medical Conditions

Medications (such as an Epipen or inhaler) that will accompany child (all medications must be clearly marked with the child's name and dosage):

Other helpful notes:

I give permission for my child's photo to be taken for use in the church's social media posts.