Children's Ministry Registration Form

2022-2023 UBC Children's Ministry Registration Form

PLEASE COMPLETE A SEPARATE FORM FOR EACH CHILD REGISTERED.
Child's Name *

First Name Last Name
Primary Parent Contact's Name *

First Name Last Name
Primary Contact's Email Address *
Primary Contact Phone Number *

Area Code Phone Number
1. Additional Adult Authorized to Pick Up your Child

First Name Last Name
2. Additional Adult Authorized to Pick Up your Child

First Name Last Name
3. Additional Adult Authorized to Pick Up your Child

First Name Last Name
4. Additional Adult Authorized to Pick Up your Child

First Name Last Name
5. Additional Adult Authorized to Pick Up your Child

First Name Last Name
Secondary Email Address
Secondary Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Child's Date of Birth *

Month Day Year
Any Allergies?
Child's Grade in School *
Do we have permission to post pictures of your child on Social Media?

Yes No
Which Program will your child be attending? (mark all that apply)

Sunday School Kids Own Worship Club 185
Any special needs or concerns you would like to share regarding your child?
Will your child be riding the church bus? *

YES NO
CHURCH BUS PERMISSION

If you clicked yes, please call our office (618) 283-1113 for information on transportation or text (618) 267-7101.

NOTE: 4 year olds must have an older sibling on the bus to ride.

I hereby give permission for my child listed above to ride the Unity Baptist Church bus to attend Club 185. I understand that my child will be under adult supervision. I further understand that in signing this registration, I release and hold harmless Unity Baptist Church. By signing this, I release and hold harmless it's trustees, officers, employee, and any volunteers from any liability, past, or future, fully and completely. I authorize the staff or designated medical professionals and/or volunteers to administer emergency medical assiatance if I cannot be reached.
Signature *

Clear
Should be Empty:

2022-2023 UBC Children's Ministry Registration Form

CHURCH BUS PERMISSION