1st Child

First Name

Last Name

Birthday

YYYY

Age

Grade

2nd Child

First Name

Last Name

Birthday

YYYY

Age

Grade

3rd Child

First Name

Last Name

Birthday

YYYY

Age

Grade

4th Child

First Name

Last Name

Birthday

YYYY

Age

Grade

5th Child

First Name

Last Name

Birthday

YYYY

Age

Grade

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parents or Guardian

First Name

Last Name

Best Phone No.

(###)

###

####

Any information will be used to provide parents with upcoming events

Emergency Contact

First Name

Last Name

Relationship

Emergency Contact Phone

The emergency contact will be contacted in the event that parent/guardian cannot be reached

(###)

###

####

Media Release

I hereby give permission for images of my child, captured during Kids On A Mission through video, photo and digital camera, to be used solely for the purposes of promotion through social media.

Permission

By entering my name in the blank below I am giving permission to attend Brownsburg Baptist Church “Kids On A Mission” and participate in all activities associated with “Kids On A Mission." As the parent/gaurdian, I do hereby authorize treatment under the direction of any licensed physician or emergency medical personnel, of the above minor child in the event of a medical emergency. This authority is granted only after reasonable effort has been made to reach me by phone at the phone numbers listed above. The undersigned assumes the responsibility for any costs connected with such treatment and hereby releases Brownsburg Baptist Church from any liability thereof. This release for is completed and signed of my own free will with the sole purpose of authorizing participation in “Kids On A Mission" and medical treatment in emergency circumstances in my absence.