FPC
FPC Child Information Form
Valid 9/15/19-9/15/20.
Child's Name
*
First
Last
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Grade
*
Child's School
*
Names and ages of siblings, if any
Parent Name(s)
*
Family Address(es)
*
Parent(s) cell phone number(s)
*
Parent email address
*
Second parent email address
Emergency contact name & phone numbers
*
Does your child have any allergies you are aware of?
*
No
Yes
List and describe allergies, being as specific as possible
*
Child's Physician
Medical Insurance Company
Policy/Group Number
Is there any information FPC staff should know?
Who is authorized to pick up this child?
*
Photograph and Video Release
We like to take occasional photos and videos for our website and other uses. Let us know if that's OK.
As parent/guardian, I
*
grant permission
do not grant permission
for First Presbyterian Church to take photographs and/or video recordings of my child:
*
First
Last
Terms
I understand that First Presbyterian Church may use photographs and/or videos for promotion, marketing, training, and/or advertising. The use of such photographs and/or videos will not constitute a violation of the rights of any person or organization. I release and hold First Presbyterian Church harmless from any and all present and future claims for compensation.
Please type your name as legal signature
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