Children’s Ministry Registration Form Page | Refton Brethren in Christ Church

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Your Child's Information

First Name *

Last Name *

Date of Birth *

Age *

Street Address *

Other Address (optional)

City *

Zip / Post Code *

Home Phone Number *

Home Church (if other than Refton Church) *

If "Other," please specify: *

*Please write "N/A" if not applicable

Parent / Guardian Information

Parent / Guardian First Name *

Parent / Guardian Last Name *

Cell Phone Number *

Email *

Parent / Guardian First Name

Parent / Guardian Last Name

Phone Number

Person(s) authorized to pick up child (other than parent / guardian): *

Emergency Contact Information

If in an emergency, the parent(s) / guardian(s) cannot be reached, please notify:

Emergency Contact First Name *

Emergency Contact Last Name *

Phone *

Relationship *

Physician Information

Name *

Phone *

Insurance Carrier *

Policy / Group Number *

Are activities restricted? *

If "Yes," please explain: *

*Please write "N/A" if not applicable

Your Child's Medical Information

Please list all information and elaborate as necessary.

Allergies: *

*Please write "N/A" if not applicable

Chronic / Recurring Conditions: *

*Please write "N/A" if not applicable

Current Medications: *

Are any medications needed during church activities? *

If "Yes," please list each medication with a dosage amount and a time to be taken: *

*Please write "N/A" if not applicable

Treatment Authorization

Please complete ONLY if your child is in the Infant or Toddler Nursery (ages 0-4)

Do you give permission for Children's Ministry Staff to use appropriate physical contact to comfort your child by hugging, sitting/rocking, and holding your child?

Yes, I give permission
No, I do not give permission and I understand that I will be called to attend to my child's needs

Do you give permission for Children's Ministry Staff to assist your child with their restroom needs by the changing of their diaper or accompanying your child to the restroom and assisting if necessary?

Yes, I give permission
No, I do not give permission and I understand that I will be called to attend to my child's needs

Do you give permission for Children's Ministry Staff to provide your child with access to a pre-made bottle/drink and/or snack that you have provided for your child?

Yes, I give permission
No, I do not give permission and I understand that I will be called to attend to my child's needs

Parent / Guardian Statement

Please read the following before agreeing to the statement:

This registration is complete and accurate. I know of no reason(s), other than indicated on this form, why my child should not participate in activities except as noted. I authorize the staff of Refton Church to seek and consent to medical treatment for my child, when either I or my assignee cannot be contacted. I understand that all necessary precautions will be taken for my child's safety and every effort will be made to contact me before such action is taken. I will not hold the church, its staff, or those supervising liable. I am aware that by selecting "I Agree", I am giving my full consent.

I Agree *

Please read the following before agreeing to the statement:

I hereby authorize the Children's Ministry adult in charge to give necessary first aid to my child. I also authorize the person in charge to obtain and consent on my behalf to whatever medical diagnosis or treatment is deemed necessary or advisable by such person for the wellbeing of my child. I am aware that by selecting "I Agree", I am giving my full consent.

I Agree *

Please read the following before agreeing to the statement:

If any information on this form changes, I will update the form with the appropriate information as soon as I am able.

I Agree *

Your Name *

Today's Date *

Media Release Form

Please read each an select ONLY one:

I give my permission for my child's photo and/or name to be included in videotapes, broadcast media, and print media to be used in Refton Church publicity and materials, whether electronic, print, digital, or electronic publishing via the internet.

Yes, I give my permission

I give my permission for my child's photo and/or name to be included in videotapes, broadcast media, and print media to be used in Refton Church publicity and materials for in-house CHURCH USE ONLY.

Yes, I give my permission for in-house, church use only

I DO NOT give my permission for my child's photo and/or name to be included in videotapes, broadcast media, and print media to be used in any publicity and materials for Refton Church.

I do not give my permission