Please - One Child Per Form

 Parents/Guardians

Parent/Guardian Name:

Address:

Email Address:

Phone Number:

Cell Number:

Child Information

Child's Name:

Child's Grade:

Child's Age:

Child's Date of Birth:

_________________________________________________

Emergency Contact1 Name & Relationship To Child:

Emergency Number1:

Emergency Contact2 Name & Relationship To Child:

Emergency Number2:

List allergies or medical conditions:

_________________________________________________

Please list person(s) authorized to pick up child:

By clicking 'send' I give permission for my child to participate in the Pioneer Club activity and release FBC-Coldwater, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage o property.  In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the director of children's ministry to make and perform the decision that they deem necessary.