* Denotes required fields.

Parent/Guardian

* First and Last Name:

* Email:

Home Phone Number:

Cell Phone Number:

Emergency Contact (If Parent Unavailable)

* First and Last Name:

* Relation:

* Phone Number:

Alternate Phone Number:

Child

* First and Last Name:

* Date of Birth (MM/DD/YYYY):

School:

* Grade Entering:
6789101112

Cell Phone Number:

Email:

Allergies/Medical Conditions/Special Needs:

Authorization for Treatment

I hereby give permission to the medical personnel selected by Century Meadows Baptist Church to provide medical care in the best interest of my son/daughter in case of a medical emergency. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Century Meadows Baptist Church to treat my son/daughter, including hospitalization, if necessary.

*Please select one
YESNO

Photo Release

I hereby give permission to Century Meadows Baptist Church to use photographs of my son/daughter and to display and/or copy the works of my son/daughter for the sole use of Century Meadows Baptist Church. I understand that these items may also be posted on the church website, official Church social media pages, or included in church publications.

*Please select one
YESNO

* I agree that the information on this form is current and accurate and by checking this box, I agree to the terms of the above agreements.

* This form was filled out by: