Children’s Class Registration Form

Child Information
Parent or Guardian Information
Emergency Contact Information
Legal Disclaimer

Child Last Name *

Child First Name *

Child Current Age *

Child's Sex *

Child Date of Birth *

Child Address *

Street Address

City

State

Zip Code

Does Child Have Allergies?

Allergies Information *

Does Child Have Any Medical Concerns?

Medical Concerns Information *

Restroom Information *

Change Diaper (if necessary)
Do Not Change Diaper (page parent)
Potty-Training
Potty-Trained

Child must be potty-trained for some classes.

Snack & Candy Information

Cheerios Allowed
Goldfish Crackers Allowed
Only Snack Parent Provides (only in case of allergies)
No Snack Allowed
Candy Allowed
No Candy Allowed

Parent/Guardian Last Name *

Parent/Guardian Cell Phone *

Parent/Guardian First Name *

Parent/Guardian Email *

Confirm Email

Section Title

Parent/Guardian Relationship To Child *

Is Parent/Guardian's Address the Same a Child's Address? *

Parent Guardian Information

Parent/Guardian Address *

Street Address

City

State

Zip Code

Additional Parent Or Guardian To Be Listed *

Additional Parent/Guardian

#2 Parent/Guardian Last Name *

#2 Parent/Guardian Cell Phone *

#2 Parent/Guardian First Name *

#2 Parent/Guardian Email *

#2 Parent/Guardian Relationship to Child *

Is #2 Parent/Guardian's Address the Same a Child's Address? *

#2 Parent/Guardian Address *

Street Address

City

State

Zip Code

We will contact Parents first, please list someone if parents can not be reached.

Emergency Contact Last Name *

Emergency Contact First Name *

Emergency Contact Relationship To Child *

Emergency Contact Cell Phone *

Medical Release *In the event that a parent or guardian cannot be contacted - I (we), the parent(s) or guardian(s) of the above stated minor, do hereby authorize adult volunteers of Northside Baptist Church as agent(s) for the parent(s) or guardian(s), to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital.

Liability *I (we), the parent(s) or guardian(s) of the above stated minor, release from any liability Northside Baptist Church, and any of its ministries or leaders in the event of an accident during the above mentioned event.

Use of Pictures for Promotional Material *I (we), the parent(s) or guardian(s) of the above stated minor, give Northside Baptist Church permission to use any pictures taken of the above minor in any promotional materials or on any social media outlet.

Parent/Guardian Signature *

By submitting this form, you agree to the above Medical Release, Liability, Use of Pictures for Promotional Material. If you have questions or concerns please contact the Church Office BEFORE submitting this form.

Children’s Class Registration Form

Section Title

Parent Guardian Information

Additional Parent/Guardian

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