Child's Name*

First Name Last Name

Called by Name

Child's DOB*

Address*

Street Address

Street Address Line 2

City State

Zip Code

Parent/Guardian Name(s)*

Preferred Phone Number*

Secondary Phone Number

Preferred Email*

Child's Grade*

My child*

has permission to leave Sunday School on his/her own to meet me in church must be picked up by parents (or person of my choice)

The following people are authorized to pick my child up from Sunday School*

Child's School*

I am interested in helping with the following*

Is your child presently being treated for an injury, sickness, or taking any medication?*

Yes No

If yes, please explain.*

Does your child have any allergies?*

Yes No

If yes, please list.*

Does your child require a special diet?*

Yes No

If yes, please describe.*

Does your child have any physical or cognitive challenges which would prevent him/her from participating in normal activity?*

Yes No

If yes, please explain.*

Anything else you'd like us to know about your child?

Medical Insurance Provider Name*

Medical Insurance Provider's Phone Number*

Name of Insured*

Policy #*

Physician's Name*

Physician's Phone Number*

Signature*

Child Information Form

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