Parent/Guardian Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Home Phone *

(###)

###

####

Parent/Guardian Name 2

First Name

Last Name

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Photo Release *

Photographs and video may be taken and possibly used for publication in church bulletins, newsletters and website. As a parent/guardian, by selecting YES below, I give permission to Reformation Lutheran Church to photograph or videotape my child(ren) while attending Reformation Lutheran Church events

YES

NO

Medical Release *

As a parent/guardian, by selecting YES below, I authorize the treatment by qualified doctor of the minor(s) listed in the event of a medical emergency while attending events at Reformation Lutheran Church

YES

NO

Information Release *

By selecting YES below, I attest that I am the parent/guardian of above mentioned children and the information provided on this form is correct.

YES

NO