2019-2020 Christian Education Registration Information & Permission Form

Contact Information

Parent/Guardian Name(s)

Date

This address will receive a confirmation email

Other Email

This address will receive a confirmation email

Cell Phone

Other Phone

Address

Children's Information

Child #1 - Name, Birthdate, Grade

Child #1 - Info: Medications/Sensory/Needs/Allergies

Child #1 - EpiPen?

Yes No

Child #2 - Name, Birthdate, Grade

Child #2 - Info: Medications/Sensory/Needs/Allergies

Child #2 - EpiPen? Yes No

Child #3 - Name, Birthdate, Grade

Child #3 - Info: Medications/Sensory/Needs/Allergies

Child #3 - EpiPen? Yes No

Child #4 - Name, Birthdate, Grade

Child #4 - Info: Medications/Sensory/Needs/Allergies

Child #4 - EpiPen? Yes No

Child #5 - Name, Birthdate, Grade

Child #5 - Info: Medications/Sensory/Needs/Allergies

Child #5 - EpiPen? Yes No

Child #6 - Name, Birthdate, Grade

Child #6 - Info: Medications/Sensory/Needs/Allergies

Child #6 - EpiPen?

In Case of Emergency

Emergency Contact Name, Relationship, & Phone

Physician's Name/Preferred Hospital

Insurance Information

Annual Multi-Program Permission

I give permission for my child, named above, to attend all program activities which have been announced and sponsored by Wildwood Presbyterian Church. If the event is held off church property, I give permission for my child to be transported to and from the event. I understand that any necessary transportation will be provided by car, van, mini-van, or truck driven by adult sponsors and/or parents. I release Wildwood Presbyterian Church, its employees, officers, volunteers, and members from any and all responsibility in case of an accident, injury, or illness while engaging in program activities and/or while traveling to and from program activities. I give my permission for my child to be treated in a medical emergency. Type name here to accept.

Pictures or videos of groups of children may appear on a password protected page on the church's website or on social media (ie church’s Facebook page). I DO/DO NOT grant permission for you to photograph/videotape my child. Specific privacy issues addressed by special request.

Do Grant Permission Don't Grant Permission Other - Please contact me

Let Me Tell You About My Child/Children

Tell us about your child/children. What are they good at? What to they love to do or not like to do? How do we know when they're frustrated? What do they need help with? What helps them calm down or change their behavior? What makes them laugh? What else should we know?

Unnamed Label

2019-2020 Christian Education Registration Information & Permission Form

Description

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