Kids' Korner Registration Form

Family Information:

Parent/Guardian Name:required

First Name

Last Name

Address:

Parent/Guardian Name 2:required

First Name

Last Name

Address:

Family Status:

Emergency Contact: Persons to whom the child may be released to

Name/Relationship/Phone

* Children cannot be released to anyone not listed here without a signed note.

Student Information:

Child's Name:required

First Name

Last Name

Grade Entering in the Fall: required

Gender:required

Birth Date: M/D/Yrequired

Child's Cell Number:

Food Allergies: required

Please use N/A if no known allergies

Other Allergies:required

Please use N/A if no know allergies

Medical Concerns:

Other Information:

Home Church:

Dear Parent or Guardian,

We are delighted to have your child meet with us in our Children's programs here at Faith Baptist Church. While we have taken steps to ensure a safe environment, we realize that accidents are a fact of life. For this reason, we request that you return the completed form as soon as possible. It will be kept on file. Should you have any questions, feel free to call 814-944-2894.

THE FAITH BAPTIST CHURCH OF ALTOONA MEDICAL PERMISSION/RELEASE FORM

Namerequired

First Name

Last Name

Email Addressrequired

Age: required

Address: required

Phone Numberrequired

Second Contact Name: requiredPlease use N/A if there is not another contact.

First Name

Last Name

Please use N/A if there is not another contact.

Phone Numberrequired

Family Physician required

First Name

Last Name

Phone Numberrequired

Insurance Co. or Planrequired

Policy #required

Please select up to 6 choices

Previous Operations or Serious Illnesses:

Special Diet (name):

Any Current Medications (list):

Date of last Tetanus shot:

Must contain a date in MM/DD/YYYY format

PERMISSION FOR TREATMENT

My permission is granted to The Faith Baptist Church of Altoona representatives and workers to obtain necessary medical attention in case of sickness or injury to my child. I the undersigned, do hereby verify that the above information is correct and do hereby release and forever discharge all Faith Baptist Church representatives or Children's workers from any and all claims, demands, actions or cause of action, past, present or future aristing out of any damage or injury while participating in the Church programs and activities. I further understand that it is my responsibility to notify Church leadership with any amended changes to the above informations. THE ATTENDING PHYSICIAN OR HOSPITAL HAS MY PERMISSION TO ADMINISTER CARE TO MY CHILD AS THEY SEE NECESSARY IN CASE OF ACCIDENT OR UNEXPECTED ILLNESS.

Do you need transportation:required

Yes

No

How will you be getting here:

School Bus

White Minibus

Walker

Parent Drop-off

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Forms

Family Information:

Emergency Contact: Persons to whom the child may be released to

Student Information:

Dear Parent or Guardian,

THE FAITH BAPTIST CHURCH OF ALTOONA MEDICAL PERMISSION/RELEASE FORM

PERMISSION FOR TREATMENT

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