Children's Ministry Family Information/Medical Release
This information is VERY IMPORTANT. Please fill out all information -- One Form per family
Father's Name
First Name
Last Name
Father's Phone Number
-
Area Code
Phone Number
Father's E-mail
Mother's Name
First Name
Last Name
Mother's Phone Number
-
Area Code
Phone Number
Mother's E-mail
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Children Information
Please fill in information for all children in your home 6th grade and under
1st Child's Full Name
*
First Name
Middle Name
Last Name
1A) Child's Birth Date
*
/
Month
/
Day
Year
Date Picker Icon
1B) Child's Grade
*
Younger than School Aged
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Grade in school in August 2021
1C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
1D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
1E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
2nd Child's Full Name
First Name
Middle Name
Last Name
2A) Child's Birth Date
/
Month
/
Day
Year
Date Picker Icon
2B) Child's Grade
Younger than School Aged
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Grade in school in August 2021
2C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
2D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
2E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
3rd Child's Full Name
First Name
Middle Name
Last Name
3A) Child's Birth Date
/
Month
/
Day
Year
Date Picker Icon
3B) Child's Grade
Younger than School Aged
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Grade in school in August 2021
3C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
3D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
3E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
4th Child's Full Name
First Name
Middle Name
Last Name
4A) Child's Birth Date
/
Month
/
Day
Year
Date Picker Icon
4B) Child's Grade
Younger than School Aged
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Grade in school in August 2021
4C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
4D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
4E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
5th Child's Full Name
First Name
Middle Name
Last Name
5A)Child's Birth Date
/
Month
/
Day
Year
Date Picker Icon
5B) Child's Grade
Younger than School Aged
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Grade in school in August 2021
5C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
5D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
5E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
6th Child's Full Name
First Name
Middle Name
Last Name
6A) Child's Birth Date
/
Month
/
Day
Year
Date Picker Icon
6B) Child's Grade
Younger than School Aged
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Grade in school in August 2021
6C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
6D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
6E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
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Medical Release
I (we) give my (our) children permission to attend Children’s Ministry events.I (we) realize that this event is being offered by the Downtown Church of Christ and will not hold them responsible for accidents. I (we) give the sponsors at events offered the right to correct and discipline our children for behavior we deem inappropriate and in order to promote a good atmosphere for all involved. I, do hereby authorize adult workers with the Downtown Church of Christ as agents for the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold harmless any physician, hospital, or other medical center for rendering of such services.
Do you agree to these terms?
*
I have read and acknowledged all above information, permissions, and give my consent.
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Insurance Information
Insurance Company Name
*
Policy Number
*
Policy Holder's Name
*
First Name
Middle Name
Last Name
Place of Employment
*
Employment Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Alt. Phone Number
-
Area Code
Phone Number
Any medical information that needs to be known?
Enter the message as it's shown
*
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