Childhood Registration Form

(Please, one form per child and indicate activity.)

Part 1: General Information Activity:______________________________________________________________ Child's Name:______________________ Gender:_________ Birthdate:__________ Age:_____ Address:_______________________________ City:____________________ Zip:__________ Grade Completed (2003-2004 school year):______ School:____________________________ Mom's Name:__________________ Home #:_______________ Work #:_______________ Dad's Name:__________________ Home #:_______________ Work #:_______________ Beeper #'s:____________________________ Cell #(s):___________________________ List Any Allergies:____________________________________________________________ Any Special Needs Your Child Has:______________________________________________ Current Medications:_________________________________ Shirt Size:________________ In Case of Emergency: Please list two (2) people other than the child's parents to contact in case of an emergency. Name:____________________ Phone #:________________ Name:____________________ Phone #:________________ Swimming Ability: Please check all that apply. Shallow:____ 3 Feet:____ 4 Feet:____ 5 Feet & Diving Area:____ Part 2: Authorization for Release of Emergency Form Permission is granted for the named child to travel with Crabapple First Baptist Church during ______________________________ (indicate activity) if needed. Permission is granted for the officials, staff, and volunteers of Crabapple First Baptist Church to administer First Aid, to obtain the services of a Licensed Physician, and to arrange transportation to the nearest hospital in case the child named above is seriously ill, injured, or requires hospitalization. Permission is also granted to the Attending Physicians to render whatever treatment they deem necessary for the child’s welfare. The responsibility for all expenses incurred will be assumed by the individuals whose signature appears below. I hereby release and discharge the Crabapple First Baptist Church staff and its volunteers from any and all liability in case of accident or any other injury which might occur to my child through administering First Aid or transportation to a medical facility. I hereby release any and all of the above from any liabilities because of any injury or damage which might occur while in the care of the staff and volunteers. Your Name (please print):____________________________________ Signature:___________________________ Date:_____________ Insurance Company Name:_________________________________ Insurance Co. Phone #:__________________________________ Name of Insured:________________________________________ Policy #:_______________________ Group #:_______________

Please indicate for which activity the child is registering, and direct any questions to the church office at (770) 475-6111. Please complete this both parts of this form and mail it with a check (if applicable) made payable to: Crabapple First Baptist Church Attention: Childhood Education 12760 Birmingham Hwy. Alpharetta, GA 3004-3700