Kids Club: Let's Glow With Jesus

Parent's/ Guardian's Name

Phone

Address

Emergency Contact

Phone

Alternate Pick-up Person

Child 1

Date of Birth:

Medical Information (Allergies, Medications, Physical Handicaps or Limitations and Other Information:

Child 2

Date of Birth:

Medical Information (Allergies, Medications, Physical Handicaps or Limitations and Other Information:

Child 3

Date of Birth:

Medical Information (Allergies, Medications, Physical Handicaps or Limitations and Other Information:

Child 4

Date of Birth:

Medical Information (Allergies, Medications, Physical Handicaps or Limitations and Other Information:

Photo Release: I permit photos to be taken of my child or children and allow Emerald Isle Baptist Church to display? on Social Media and Website?

YES NO

I give permission for my above-named child to participate in Kid's Club Activities at Emerald Isle Baptist Church. I further agree that Emerald Isle Baptist Church will be relieved of all responsibility in the event of an injury. In the event of an emergency and that I cannot be contacted, I hereby authorize an adult leader of this activity, as an agent for me, to consent to any X-ray examination, medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where services are rendered, either at a doctor's office or a hospital. I expect to be contacted as soon as possible.

I agree I do not agree

Description

October 16, 2026

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Kids Club: Let's Glow With Jesus

Description

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