Central Christian Church701 N. Delaware Indianapolis, INChildren’s and Youth Ministries Child's Name * First Name Last Name Age/Grade * Birthdate * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Parent 1 Name * First Name Last Name Parent 1 Phone * (###) ### #### Parent 1 Email * Parent 2 Name First Name Last Name Parent 2 Phone (###) ### #### Parent 2 Email Emergency Contact (other than parents) * Relationship of Emergency Contact Phone for Emergency Contact * (###) ### #### Known Allergies or Medical Conditions 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 * (###) ### #### 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 (###) ### #### Optional Additional Information 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 Please alert leaders of any changes in information. This form is effective October 2017-September 2018 Thank you!
