Child's Name:
Age:
Date of birth (YYYY-MM-DD format)
Home Phone (or cell phone of parent)
Address
City
State
Zip code
School
Grade
Parent/Guardian #1 Name
Cell
Email
Parent/Guardian #2 Name
Alternate emergency contact (name and phone number)
I give Faith Baptist Church permission to use Ministry Sponsored photographs of my child for the church website. YesNo
List any medical conditions or allergies your child has:
Explain how the above-mentioned conditions may manifest during our programs:
List all medications your child takes regularly:
Any information to share with EMT in event of medical emergency:
Any information you can add that would best help us with your child/teen:
Health Insurance Company
Policy number
Policy holder
Doctor
Doctor's phone number
Emergency phone numbers
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