Children's Ministry Form 2023-2024

Children's Ministry Registration Form

2023-2024
Child's Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Date
Gender
Grade
School
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Can we email and text the parent/guardian at the above contact info via the church management software, Breeze (i.e. about family/children programs, events?)

YesNo
Emergency Contact (other than parent listed above)

First NameLast Name
Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health
Insurance Company
Policy Number
Group Number
Family Doctor/Medical Group Name
Please list any allergies, behavioral concerns or medical information you feel necessary to share with us:
In the event that my child requires medical attention and I cannot be reached immediately, I give Tuckahoe Presbyterian Church staff, volunteers, teachers or youth directors to seek and authorize medical treatment.
Electronic Signature of Parent/Guardian
Today's Date

MonthDayYear
Date
Video/Photo Release
Unless I have indicated otherwise below, I understand that pictures, video, recordings, and/or other audio recordings of my child may be displayed in brochures, newsletters, video productions and/or other electronic media designed for the communication purposes of Tuckahoe Presbyterian Church. I understand that my child will not be identified by name without my express written permission.
Type a question

I do not want any video or audio or pictures of my child displayed on the church property or in the brochures or newsletters, video productions or other electronic media designed for the internal communication purposes of Tuckahoe Presbyterian Church.
Electronic Signature of Parent/Guardian
Today's Date

MonthDayYear
Date
Should be Empty:

Children's Ministry Registration Form

Health

Video/Photo Release