Student's Name(Required)Street Address(Required)City(Required)State(Required)ZIP(Required)Home PhoneCell PhoneGrade CompletedAgeBirthdate MM slash DD slash YYYY Parent's/Guardian's Name(Required)Emergency Contact Number(Required)Allergies or Special NeedsDo you attend Church? (If so, where)Who May Pick Up This ChildNameAuthorized pickup person 1PhoneNameAuthorized pickup person 2PhoneThe undersigned gives permission to his or her child to participate in the above named activity and releases Carrville Baptist Church, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by the undersigned for any member of his family, in attendance, and the undersigned agrees to defend and indemnify Carrville Baptist Church, its officers, employees, and agents from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the director of children's ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above.Signed(Required)Date(Required) MM slash DD slash YYYY
