Salem KIDS 2017-2018 Registration Form

2017-2018 Registration Form
Child's Name *

First Name Last Name
Date of Birth *

- Month - Day Year
Gender: *

Male Female
Grade: *
School:
Allergies/Special Needs/Concerns:
This child will attend (check all that apply): *

Sunday School 9am Sundays 10:15am TeamKID
Family Information
Mother/Guardian: *

First Name Last Name
Cell Phone *

- Area Code Phone Number
Text?

Yes No
E-mail
Father/Guardian:

First Name Last Name
Cell Phone:

- Area Code Phone Number
Text?

Yes No
E-mail

Address *

Church Home:

Salem None Other option
Emergency Information:
Emergency Contact Name:
Emergency Contact Number:

- Area Code Phone Number
Pick-Up Permission - In addition to the mother, father, and emergency contact named on this form, these people have permission to pick up my child/children:
PHOTOS: I understand that photos and videos may be taken of church activities which may include my child/children and may be used in print or on the church's website. I consent to these photos/videos being used in this manner. This authorization will remain in effect indefinitely, unless cancelled in writing by the undersigned.
MEDICAL AUTHORIZATION: In case of a medical emergency, I hereby give authority to any hospital and/or emergency medical personnel to render immediate medical aid, including transport if necessary, for my child, named above, as may be required at the time for his/her health and safety. This authorization will remain in effect indefinitely, unless cancelled in writing by the undersigned.
Parent/Guardian Signature: *

Clear
Type Parent/Guardian name here: *
Today's Date:

- Month - Day Year
Date
Should be Empty:

2017-2018 Registration Form