Child's First Name: 

Child's Last Name: 

Child likes to be called:    Age:

Parent/Guardian's First Name: 

Parent/Guardian's Last Name: 

Street Address:     City:   State:  Zip:

Telephone:     Email:   

Do you currently attend a church regularly?  Choose One Yes No   If so, which one? 

If so, where is your church located?  City:    State: 

Do you need bus pick-up?: Choose One Yes No

If bus pick-up is needed, indicate the address where

the child should be picked up if different from above:  

Is there anything we should know about your child? (Health concerns, food allergies...etc.)

In case of injury, what doctor should we contact?  Name:    Telephone:

Names of others we may contact in case of emergency:

Emergency Contact 1:     Telephone: 

Emergency Contact 2:     Telephone: 

By checking this box, I allow my child to participate fully in games, crafts, snacks, and Bible activities during the week of July 19-23.  I understand that these games and activities may involve running, jumping, throwing, catching, and other active exercises during which injury is always possible.  I hold First Baptist Church and any of its members and staff free from all liability of injury that may result from participation in such games and activities.