Child's Name *

First Name

Last Name

Child's date of birth *

MM

DD

YYYY

Parent/Guardian Name #1 *

First Name

Last Name

Parent #1 Phone *

(###)

###

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Parent/Guardian #2 Name

First Name

Last Name

Parent #2 Phone

(###)

###

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Alternate Emergency Contact Phone

(###)

###

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Photo Permissions (Internal purposes)

I permit photos taken of my child to be displayed on notice boards in the church/youth room or other internal purposes.

Photo Permissions (External purposes)

I permit photos or videos taken of my child to be displayed in church publications, e.g. social media, website, newsletters, brochures, etc.

Medical & Liability Release *

In the event of sickness or medical emergency, I request that my child receive any medical attention or treatment deemed necessary, therefore I give permission to any hospital, doctor, and/or health care provider to transport, treat and/or admit for care my child. I understand that I am responsible for all expenses and charges for the treatment and care of my child. In the event that I am not present at the time of the emergency or cannot be contacted, my care has been entrusted to the staff and designated ministry leadership of Green Point Baptist Church.

Name *

The name of the person filling out this form

First Name

Last Name

Today's Date *

MM

DD

YYYY