Child's Name *

First Name

Last Name

Parent or Guardian Name (Emergency Contact) *

First Name

Last Name

Parent or Guardian Address (Emergency Contact) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian Phone Number (Emergency Contact) *

(###)

###

####

Secondary Emergency Contact Name *

First Name

Last Name

Secondary Emergency Contact Phone Number *

(###)

###

####

Medical Release *

Yes, I give permission for Union Church of Quincy to treat my child.

No, I do NOT give permission for Union Church of Quincy to treat my child.

Photo Release *

Yes, I give permission for my child to be photographed and/or videotaped for promotional purposes only.

No, I do NOT give permission for my child to be photographed and/or videotaped for promotional purposes only.

Consent *

Yes, I agree that I have answered all the questions accurately.

By submitting this form, I agree to all terms listed.