Kids for Christ Registration 2014-2015

Kids For Christ Begins Sept. 17, 2014

Kids For Christ Registration 2014-2015

* Indicates required field

Child's Name *

First

Last

What grade is your child in? *

Parents Name *

First

Last

Phone Number *

Cell Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Emergency Contact & Phone number *

Relationship to you? *

Medical Authorization To Grant Consent

Physician & Phone number *

Local Hospital *

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by the above name doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist and the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. *

Yes No Refusal to Consent

Facts concerning the child’s medical history, including allergies, medications being taken and any physical impairments to which a physician should be alerted. *

yes no

Church Bus Authorization

If Yes- List Allergies, Medications being take. *

If you have a Risingsun or Bradner address the church bus would be able to pick up your child (children) if you live outside the Risingsun/Bradner area, Please contact us and we will evaluate bus transportation for you. Please contact us by email - [email protected] or call 419-457-3971.

Do You need Transportation? *

Yes No

Location for bus pick up *

Location for bus drop off *

Submit