Children in Action Registration

Child's Name: *

Date of Birth: *

Parent/Guardian Name: *

Address: *

Home Phone: *

Cell/Work: *

Parent Email: *

Allergies/Medical Information/Special Diet or Other Concerns: *

Emergency Contact Name: *

Phone: *

Emergency Contact Name: *

Phone: *

Name of person(s) who may pick up child other than parent/guardian and relationship to child: *

Please list any custody arrangements that we need to be aware of: *

Siblings' names and ages (please include last name if different): *

Media Release *

Yes
No

Do you grant permission to Community Central Church to photograph your children?

Release of Liability *

Yes
No

Do you grant permission for your children to participate in all activities and release Community Central Church and it's agents from all liability?

Medical Release *

Yes
No

Do you grant permission to Community Central Church to give any medical treatment deemed advisable in the event of injury or accident?

Special Needs *

Yes
No

Do any of your children have any special needs that we should be aware of? (NOTE: If "Yes," our church staff or volunteers will contact you to discuss.)

Emotional/Behavioral Disorders *

Yes
No

Have any of your children ever been diagnosed with emotional or behavioral disorders? (NOTE: If "Yes," our church staff or volunteers will contact you to discuss.)

Authority to Sign *

Yes
No

Do you have full power and authority to grant permission to complete this form on behalf of your child?