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What We Believe
Meet Our Staff
Meet Our Elders
Young Adult Ministry
Children’s Ministry Registration
Children's Ministry Registration
Step 1 of 3 - Child and Parent Information
Nursery (0-24 months)
Address Line 2
State / Province / Region
ZIP / Postal Code
Primary Phone Number
Secondary Phone Number
Medical and Security Information
Please list all adults who can pick up your child from Duplain
They will need the ID claim tag issued at drop-off
Does your child have any allergies?
Please list them
Does your Child take medications or have medical conditions we should be aware of?
Please explain and list any medications.
Insurance Company Name
Insurance Policy Number
Emergency Contact Information
An emergency contact must be an individual other than a parent or guardian. This person will be contacted in case of an emergency when the parent's or guardians cannot be reached
Emergency Contact Name
Relationship to Child
Aunt or Uncle
Sibling (over 18)
Signature and Release
I (Parent/Guardian) do hereby give my permission for my child to receive emergency medical care. In addition, I will not hold Duplain Church of Christ of St. Johns, MI, or any employee or representative thereof, responsible for any expense, claims, or liability arising from an injury to my child. Furthermore, I authorize the use of any media containing my child for the sole purpose of church promotion with the understanding that my child's personal information including name will not be used. I also agree to sign this form by way of electronic submission below.
This field is for validation purposes and should be left unchanged.