Child Registration Form

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CHILD REGISTRATION FORM

CHILDREN

* Indicates required field

Child's Name *

First

Last

Date of Birth *

Age *

Grade *

Allergies *

Does your child require special assistance in the classroom? (If, YES, please complete the special assistance form below) *

Yes No

Child's Name *

First

Last

Date of Birth *

Age *

Grade *

Allergies *

Does your child require special assistance in the classroom? (If, YES, please complete the special assistance form below) *

Yes No

Child's Name *

First

Last

Date of Birth *

Age *

Grade *

Allergies *

Does your child require special assistance in the classroom? (If, YES, please complete the special assistance form below) *

Yes No

PARENTS

Parent / Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Cell Phone *

Text? *

Yes No

Work Phone *

Parent's Email *

Permission / Authorization *

I hereby give my permission for my child(ren) to participate in Sunday School at New Song United Methodist Church (New Song UMC). I understand the nature of the program and do hereby release New Song UMC, along with its staff and volunteers, from any responsibility and liability for injuries or illness that my child(ren) sustains during their participation. In the event of an emergency, I authorize an adult leader to make every effort to contact myself; if contact is unsuccessful, I agree to allow New Song UMC to act as an agent for my child(ren) and call 9-1-1 for medical, dental or surgical diagnosis/treatment, and/or hospital care as advised/supervised by a physician, surgeon or dentist. I give my permission for the use of my child(ren) pictures by NSC for use on the NSC website.

Enter the information requested above and by typing your name in the signature box.

Signature *

Month *

Day *

Year *

Submit

SPECIAL ASSISTANCE INFORMATION

(If you have more than 1 child with special needs, please complete this section for EACH child)
Please complete only the sections that require special assistance. Please describe their need and the best way that we can develop a plan of action all will follow.

* Indicates required field

Child's Name *

First

Last

My Child needs special assistance with: *

Motor / Mobility Seizures / Other Medical Communicating Vision Hearing Eating Toileting Learning

Does your child need assistance in participating in activities/tasks *

Yes No

If yes, explain *

Does your child need assistance in participating with others *

Yes No

If yes, explain *

I would like to talk with a staff member about my child having a… *

“buddy” (trained volunteer) during church services and other church activities. safety plan if my child would need to be removed from the classroom for a sensory or calming break.

Submit