EmailMe Form - Kids' Connection 2023-24 Registration

Child 1

Name *

First Last

Gender *

Male

Female

Age *

Birth Date *

Grade *

School Attending *

Medical Concerns/Allergies/Special Needs Details *

Child 2

Name

First Last

Gender

Male

Female

Age

Birth Date

Grade

School Attending

Medical Concerns/Allergies/Special Needs Details

Child 3

Name

First Last

Gender

Male

Female

Age

Birth Date

Grade

School Attending

Medical Concerns/Allergies/Special Needs Details

Parent/Guardian Information

Parent/Guardian Name *

First Last

Relationship to child(ren) *

Address *

Street Address City State / Province / Region Postal / Zip Code

Primary Phone *

### - ### - ####

Other Phone

### - ### - ####

Email *

Emergency Contact

In case parent/guardian is unreachable.

Emergency Contact

First Last

Relationship to child(ren)

Emergency Contact Phone

### - ### - ####

Additional

Your Home Church *

Invited By *

Release Waiver

I release the above children into the care and protection of Chatham Bible Church, recognizing that they will do everything possible to create a safe environment for my child(ren). In the event that medical attention is needed, I give Chatham Bible Church permission to care for my child(ren) as appropriate. I understand that someone from Chatham will attempt to contact me as soon as possible in the event of an emergency.

Release Agreement *

I have read & agree to the release waiver above.