Central Christian Church

701 N. Delaware      Indianapolis, IN

Children’s and Youth Ministries

Child's Name *
Child's Name
Birthdate *
Birthdate
Address *
Address
Home Phone *
Home Phone
Parent 1 Name *
Parent 1 Name
Parent 1 Phone *
Parent 1 Phone
Parent 2 Name
Parent 2 Name
Parent 2 Phone
Parent 2 Phone
Phone for Emergency Contact *
Phone for Emergency Contact
Person Other Than Parents to Whom Your Child May Be Released *
Person Other Than Parents to Whom Your Child May Be Released
Phone of Person to Whom Your Child May Be Released *
Phone of Person to Whom Your Child May Be Released
Second Person Other Than Parents to Whom Your Child May Be Released
Second Person Other Than Parents to Whom Your Child May Be Released
Phone of Second Person Other Than Parents to Whom Your Child May Be Released
Phone of Second Person Other Than Parents to Whom Your Child May Be Released
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. *
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. *
Please alert leaders of any changes in information. This form is effective October 2017-September 2018