Word Of Life Children's Ministry Registration Form 2025-2026 School Year
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Medical Facility
*
Name of Physician/Pediatrician
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Any Allergies or Medical Conditions?
*
Yes
No
Please give details
Do you want to add something about your child?
*
I understand and agree with the following statements:
*
I am the parent/guardian of the child indicated above.
If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.
I am giving my permission to have my child's picture or video taken by Word Of Life to use for Word Of Life Church purposes (Ex; website, posters, emails)
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: