KCC Youth Church Registration

This form must be filled out by parents or guardians. One form per child please.

Child's Information

Child's Name

Birthday

Day

Month

Year

Details of any regular medication, medical conditions (e.g. asthma, epilepsy, diabetes) or disability that we need to be aware of. Please write details in box below, or write 'None'.

Details of any allergies or dietary requirements. Or write 'None'.

Parent / Guardian Information

Emergency Contact Name & Relationship to Child

Emergency Contact Number

Email Address

Alternative Emergency Contact Name & Relationship to Child

Alternative Emergency Contact Number

Consent & Permissions

I give permission for Kingswinford Christian Centre to use my child's image in any appropriate publicity.

Yes

I give permission for my child to take part in all regular activities at Kingswinford Youth Church.

Yes

I understand that my child will be under the care of adults approved by the church, and although they will take all reasonable care of my child, they cannot be held responsible for any loss, damage or injury suffered during or as a result of activities.

Yes

In an emergency and/ or if I am not contactable, I am willing for my child to receive doctor/ hospital treatment, including anaesthetic if necessary.

Yes

Details of who will be collecting your child at the end of the evening (include names and relationship to child.) If someone other than the people below will be collecting your child, let one of the team know beforehand.

Signed

Parent / Guardian Name & Relationship to Child

Date

Day

Month

Year