Child Enrollment | Central Christian Church

Child's First Name:

Child's Last Name:

Age/Grade:

Child's Birthdate:

Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

Home Phone:

Parent 1 First Name:

Parent 1 Last Name:

Parent 1 Phone Number:

Parent 1 Email Address:

Parent 2 First Name:

Parent 2 Last Name;

Parent 2 Phone Number:

Parent 2 Email Address:

Emergency Contact (other than parents):

Relationship of Emergency Contact:

Emergency Contact Phone Number:

Known Allergies or Medical Conditions:

First Name of Person Other Than Parents to Whom Your Child May Be Released:

Last Name of Person Other Than Parents to Whom Your Child May Be Released:

Phone Number of Person to Whom Your Child May Be Released:

First Name of Second Person Other Than Parents to Whom Your Child May Be Released:

Last Name of Second Person Other Than Parents to Whom Your Child May Be Released:

Phone Number 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 option 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.

Opt-In

By checking this box, I understand that I am to alert leaders of any changes in information. This form is effective October 2017-September 2018

Child Family Info

Central Christian Church

701 N. Delaware Indianapolis, IN

Children’s and Youth Ministries

SUNDAY WORSHIP | 10:30 AM

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