Children's Ministry Registration Form Page

Fields marked with an * are required

Your Child's Information


*Please write "N/A" if not applicable


Parent / Guardian Information



Emergency Contact Information

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



Physician Information


*Please write "N/A" if not applicable


Your Child's Medical Information

Please list all information and elaborate as necessary.


*Please write "N/A" if not applicable

*Please write "N/A" if not applicable

*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)



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.

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.

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.



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.

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.

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.