Parent/Guardian 1 *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

This is the address where my child(ren) will be picked up and dropped off

If applicable

Yes

Parent/Guardian 2 *

First Name

Last Name

Phone *

(###)

###

####

Address if different from primary address of children

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

This is the address where my child(ren) will be picked up and dropped off

If applicable

Yes

Emergency Contact (other than guardians) *

First Name

Last Name

Phone Number *

(###)

###

####

Adults authorized to pick up child(ren)

First Name

Last Name

Adults authorized to pick up child(ren)

First Name

Last Name

*By registering my child(ren) for FBC Clay Children’s Ministry I authorize that my child’s image may be photographed, filmed, and used in video, print and web presentations. *By giving my email address, I understand that I will be added to FBC Clay Children’s Ministry mailing list. FBC Clay will not give your personal information to any third parties. *I give my permission for my child to participate fully in FBC Clay Children’s Ministry including snacks, games, transportation, and will not hold FBC Clay responsible for any accidents that might occur. In case of emergency, I understand that every effort will be made to contact the guardians of the child(ren). In the event that I cannot be reached, I hereby give permission for the medical personnel selected by the church staff to secure proper and necessary treatment for my children. *

Yes