Child/Youth Registration

1Parent / Guardian

2Children

3Emergency Contact

4Authorization

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian - Relationship to the Child(ren)

Parent/Guardian - Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian - Home Phone*

Parent/Guardian - Cell Phone*

Parent/Guardian - Cell Phone Carrier (ie:Verizon/AT&T)*

(For Texting Purposes Only)

Parent/Guardian - Email*

Parent/Guardian - Church You Attend (if applicable)

Spouse/Guardian #2

Spouse/Guardian #2 - Name

First Last

Spouse/Guardian #2 - Relationship to the Child(ren)

Spouse/Guardian #2 - Cell Phone

Spouse/Guardian #2 - Email

Spouse/Guardian #2 - Church You Attend (if applicable)

Home Information

Address where the child(ren) resides*

Street Address Address Line 2 City State ZIP Code

Home Phone

Other than a Parent/Guardian, who will be transporting the child(ren)?

Name

Phone Number

Legal Release

I (we), by signing this release, do hereby agree to the following: In the event of an accident or injury occurring on the premises of Faith Baptist Church, to myself (ourselves) and/or anyone else under my (our) care, control, or custody, do hereby agree to hold Faith Baptist Church and its insurance company free and harmless and to present no claim for damages against Faith Baptist Church or its insurance company.

Name of the Adult Authorizing the Legal Release and Approve of Emergency Medical Treatment if needed for the child(ren)*

First Last

Extra Adult Emergency Contact

In case of emergency, accident or illness, reasonable efforts will be made to contact the parent/guardian. Please provide the emergency contact of a relative or friend to contact if you cannot be reached. Please advise them that you have put their name on this form. Please advise us of any changes throughout the year.

Emergency Contact - Name*

First Last

Emergency Contact - Relationship to the child(ren)*

Emergency Contact - Cell Phone*

Emergency Contact - Home Phone

Authorized Sign-Outs

Please list the names, relationships & phone numbers of the additional ADULTS (6th grade or older) authorized to sign your children (age 12 and under) out of FBC ministries. Any changes in sign out authorization need to be made at the time, or before, your child is dropped off.

Name #1

Relationship to the child(ren) #1

Phone Number #1

Name #2

Relationship to the child(ren) #2

Phone Number #2

Name #3

Relationship to the child(ren) #3

Phone Number #3

Name #4

Relationship to the child(ren) #4

Phone Number #4

Is there anyone specific who CAN NOT pick up your child?

Please list the names and relationships of anyone who CANNOT pick up, or have contact with, your child.

One per line:

Authorization

I have the authority to grant permission and agree to the conditions of this registration form.

Your Name

First Last

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Contact Us

Who would you like to reach?*
Your Name*
First Last
Email*
Message*
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