Child's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

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Parent 1 Name *

First Name

Last Name

Parent 1 Phone *

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Parent 2 Name

First Name

Last Name

Parent 2 Phone

(###)

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Phone for Emergency Contact *

(###)

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Person Other Than Parents to Whom Your Child May Be Released *

First Name

Last Name

Phone of Person to Whom Your Child May Be Released *

(###)

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Second Person Other Than Parents to Whom Your Child May Be Released

First Name

Last Name

Phone of Second Person Other Than Parents to Whom Your Child May Be Released

(###)

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I give my permission for pictures/video of my child to be used by Central Christian Church on website, Facebook and other social media, eConnections, other church publications. *

I give permission

I do not give permission

By clicking on the first checkbox below, I give permission for my child to participate in activities at Central Christian Church and agree to hold leaders harmless. I also give permission for leaders of those ministries to secure medical care in the event of an emergency or inability contact me. *

I agree to participation of my child and, if necessary, securing of medical care.

I am not interested in participation for my child at this time