Child Information Form

Child's Name*

First NameLast Name

Called by Name

Child's DOB*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Parent/Guardian Name(s)*

Preferred Phone Number*

Format: 000- 000-0000.

Secondary Phone Number

Format: 000-000-0000.

Preferred Email *

Child's Grade*

has permission to leave Sunday School on his/her own to meet me in churchmust 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*

YesNo

If yes, please explain.*

YesNo

If yes, please list.*

YesNo

If yes, please describe.*

YesNo

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*

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