cbh-registration - Trinity Gardens Church of Christ

Family Name(s) *

Name of Child *

Date of Birth *

(Format: MM/DD/YYYY)

Phone Number

Mobile Number

Email *

Please give the names of other persons who you authorize to collect your child/ren in your absence, while in the care of the above-named group *

Are there any family situations we should be aware of? Eg:custodial issues, other matters (please specify) *

I consent to my child taking part in the approved program of activities for the Bible Hour Ministry *

I Consent

I Do Not Consent

I consent to my child viewing VHS tapes or DVDs rated (G) General. I understand that all material will be previewed by a leader to check suitability. *

I Consent

I Do Not Consent

I give my permission for my child to be photographed or videotaped. I understand that the image may be displayed in the church publications, church buildings or website. I understand that as a precaution my child’s name will not be published or linked with photographs. *

I Consent

I Do Not Consent

Please check if your child suffers from any of the following:

Is your child presently taking medication? *

Yes

No

If you answered yes to the question above, please state the name of the medication, dosage, etc.

If you answered yes to the question about medication, does your child self-administer?

Yes

No

Is your child allergic to:

Penicillin

Bee stings

Other drugs or food

Please list any physical or special needs: (eg. ADHD, ED, Autism, etc.) *

I authorize the leader/s in charge of the above mentioned group where it is impractical to communicate with me, to arrange for my child to receive such medical or surgical treatment as the leader/s may deem necessary at any time during the activities of Trinity Gardens Church of Christ. I further authorize the use of Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment. I appreciate that every care will be taken by the leaders and those connected with that group cannot be held responsible for personal injury, loss or theft of property affecting my child.

I agree

I do not agree

Enter your full name to serve as your signature *