City Kids Event Registration — City Church Baltimore

Home Church

Please tell us which church you regularly attend, OR list the organization through which you are registering for this event (i.e. Christian Community Center)

For which event are you registering?

Please list all children registering for this event.

Child 1

First Name

Last Name

Age

Birth Date

YYYY

Grade Last Completed

Child 2

First Name

Last Name

Age

Birth Date

YYYY

Grade Last Completed

Child 3

First Name

Last Name

Age

Birth Date

YYYY

Grade Last Completed

Child 4

First Name

Last Name

Age

Birth Date

YYYY

Grade Last Completed

In the event that my child becomes ill or injured, I authorize the accompanying adults to contact the parent and/or legal guardian and follow his/her instructions.

Mother’s Name

First Name

Last Name

Phone Number (Home)

(###)

###

####

Phone Number (Cell)

(###)

###

####

Father’s Name

First Name

Last Name

Phone Number (Home)

(###)

###

####

Phone Number (Cell)

(###)

###

####

Parent Email

Please list the email address you check most often. We will be sending you important information about this event.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If the parent or legal guardian is not available, please contact the following person and follow his/her instructions.

Emergency Contact Name

First Name

Last Name

Relationship to Child

Phone Number (Home)

(###)

###

####

Phone Number (Cell)

(###)

###

####

If no one can be reached in the event of an EMERGENCY, I hereby give my permission to the physician selected by the adult leader to hospitalize, secure proper treatment for, and to order injection, anesthesia for surgery to my child.

Primary Physician Name

First Name

Last Name

Phone Number

(###)

###

####

Medical Insurance Carrier

Policy Number

Please list any known allergies, dietary restrictions, medical conditions or drug reactions:

Specify child if you are registering multiple

Photo Release

I give permission for my child’s photo to be taken and potentially used in church communications (i.e., web site)

Parent Signature

Please provide your electronic signature.

First Name

Last Name

Today’s Date

YYYY