Children's Ministry Registration

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Child's Information
Child's Name*
First Last
Child's Birthday*
Child's Grade 2016-2017 School Year*
Parent's Information
Parent's Name*
First Last
Parent's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone Number*
Secondary Phone Number
Parent's Email*

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*
First Last
Relationship to Child*
Contact Number*

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.
Signature*
Date*
Name
This field is for validation purposes and should be left unchanged.

Child's Information