Children & Preschool Ministry
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KidzLife Registration - Fall 2016
Complete this form for each child attending KidzLife for the 2016/2017 school year.
Child's First Name
Child's Last Name
2016/2017 School Grade
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
2016 NEC Permission/Release Form on File
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.
Does your child have allergies to: (select all that apply)
Medications (list below)
Food (list below)
Does your child suffer from, has ever experienced, or is being treated for any of the following: (select all that apply)
Frequently Upset Stomach
Date of last tetanus shot:
Does your child wear: (select all that apply)
Please list and explain any major illnesses the child experienced during the last year and also list any other details we may need to know.
For your information, we expect each child to conform to these rules of conduct:
No possession or use of alcohol, drugs, or tobacco
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
Participation with the group is expected
Respect one another, staff, and adult leaders
Respect and comply with event schedules
Children who fail to comply with these expectations may be sent home at their parents’ expense.
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the child named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/We affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the child named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Northeast Church Children’s Ministry Leadership.
I/We give my permission to Northeast Church to pick up my child and transport to all events and programs. I/We understand that he/she will be picked up and dropped off at the address listed on this form, unless otherwise instructed. I/We understand that my child will not be able to ride the bus without this form being filled out. I/We understand that the bus is offering rides to children in the 1st grade and above. Anyone under the 1st Grade cannot ride the bus unless accompanied by an authorized parent/guardian. This permission slip is good until December 31, 2016. A new form will be issued on January 1, 2017 for completion. If any of the given information on this form changes, the parent is responsible for notifying Northeast Church so that accurate records are kept in case of emergency.
I hereby grant full permission to Northeast Church, A Southern Baptist Fellowship, to use either my photograph and name (if necessary) or my child’s photograph and name (if necessary) in any publication or advertising materials (printed or electronic). This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my photograph and/or name or my child’s photograph and/or name.
I agree with the consent/agreement form above for my child.
Children & Preschool Ministry
Submit My Story