Registration

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Child(ren) Information

Child #1 Name * This field must contain Child's Name

Shirt Size * This field must contain Child's Name

Birthday * This field must contain birthdate

Age * This field must contain age

Grade Entering in Fall * This field must contain the grade

School * This field must contain the your school

Child #2 Name *

Shirt Size *

Birthday *

Age *

Grade Entering in Fall *

School *

Child #3 Name *

Shirt Size *

Birthday *

Age *

Grade Entering in Fall *

School *

* Required if applicable

Parent(s) Information

Parent/Guardian Name This field must contain Parent/Guardian Name

Phone Number This field must contain phone number

Street Address, apt # This field must contain Parent/Guardian Name

City This field must contain Parent/Guardian Name

State

Zipcode This field must contain Parent/Guardian Name

Required

Emergency Contact Information

Name This field must contain Parent/Guardian Name

Phone Number This field must contain phone number

Relationship to Child This field must contain Relationship

Required

People who have permission to pick up my child(ren) when I am unable

Person 1 *

Phone Number *

Relationship to Child *

Person 2 *

Phone Number *

Relationship to Child *

* Required if applicable

Medical

Medical Ins. Provider

Dr's Name

Policy #

Dr's Phone Number

Allergies, Medical or Other Special Conditions we should be aware of

Yes No

List of Allergies or other conditions

Will your child be carrying an epipen?

Yes No

Liability

I release and agree to hold harmless Shoreline Community Church, it's staff and volunteers from any liability for illness or injury while my child is enrolled in Children's Ministry Activities, and I agree to pay for all medical expenses.

Yes No

Required

Permissions

Photos

I give permission for photos to be taken of my child participating in activities used only for Shoreline promotional materials.

Yes No

Transportation

I give permission for my child to be transported in a vehicle for Children's Ministry related activities.

Yes No

Required

Payment Method

Cash Check (write check out to Shoreline Community Church) Credit Card (will be taken on first day of being dropped off)

Required

Signature

I acknowledge that I have read and completed the above information

This field must contain your signature

This field must contain the date

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