Registration Form: Gospel Kids @ Black Springs Baptist Church

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Child's Name: *

Age: *

Birthdate: *

Grade: *

Home phone #: *

Mother cell phone #: *

Mother email: *

Father cell phone #: *

Father email: *

Street address: *

City: *

State: *

Zip: *

Emergency contact name/ phone number/ relationship: *

Does child have any special needs? Please list and explain: *

Home church: *

As parent/ guardian, I authorize treatment by a qualified and licensed medical doctor for the child named above in the event of a medical emergency which in the opinion of the medical doctor may endanger the life of the child, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to reach me. *

Yes

I give permission to use photos and videos of the child named above in church publications. *

Yes

I give permission for the child named above to ride home from black Springs Baptist Church with a specified person, listed here. (if does not apply, use "n/a" here) *

Signed (*parent/guardian authorization): *

Relationship to child: *

*Signee must be parent/guardian of child named above.

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