Children's Hand Chime Choir 2017-2018 Registration Form » Mary Esther United Methodist Church

Child's Information*

Child's First and Last Name	Child's Age	Child's Birthdate (mm/dd/yyyy)

School Name and Dismissal Time*

Child's School Name	Child's Dismissal Time

Child's Allergies and/or Medical Concerns

Do you need to register a second child?*

Yes
No

Child 2's Information*

Child 2's First and Last Name	Child 2's Age	Child 2's Birthdate (mm/dd/yyyy)

School Name and Dismissal Time*

Child 2's School Name	Child 2's Dismissal Time

Child 2's Allergies and/or Medical Concerns

Do you need to register a third child?

Yes
No

Child 3's Information*

Child 3's First and Last Name	Child 3's Age	Child 3's Birthdate (mm/dd/yyyy)

School Name and Dismissal Time*

Child 3's School Name	Child 3's Dismissal Time

Child 3's Allergies and/or Medical Concerns

Emergency Contact(s)*

Please provide the name, phone number, and relationship with the child for each person.

Authorized Pick-Up List*

Please provide a list of all adults authorized to pick up your child(ren), including your own name. We will only be releasing students to these people and a picture ID will be required to prove identity.

Home Address*

Street Address Address Line 2 City State ZIP Code

Mother's Name*

First Last

Mother's Phone Number (Home/Cell)*

Mother's Phone Number (Work/Other)

Mother's Email Address*

Father's Name*

First Last

Father's Phone Number (Home/Cell)*

Father's Phone Number (Work/Other)

Father's Email Address

Home Church

I give permission for my child’s photo to be taken at MEUMC.*

Yes
No

*I understand and give permission for photos taken by the Children’s Ministry may be displayed on: bulletin boards, art projects, or on the Mary Esther UMC website and Facebook page

PERMISSION TO ATTEND ACTIVITIES AWAY FROM MARY ESTHER UNITED METHODIST CHURCH

I hereby consent to participation by the above named child/children in activities that are scheduled away from Mary Esther United Methodist Church. I understand that my child will be under supervision on Mary Esther United Methodist Church staff or designated volunteers. In the event that I cannot accompany my child, I give permission for my child to ride with a designated driver in the Mary Esther United Methodist van or bus.

On the rare occasion an emergency requiring medical treatment develops, the designated Supervisor of this activity will make every attempt to contact parent/guardian/emergency contact prior to exercising the emergency treatment consent.

In the event of injury and/or illness of the above named child/children, I hereby authorize the Mary Esther United Methodist Church Supervisor of the activity to obtain and consent to whatsoever medical treatment the medical professional deems necessary. I do hereby release Mary Esther United Methodist Church and the event supervisor from any and all claims which may arise from obtaining and consenting to medical treatment.

Electronic Signature of Parent/Guardian*

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Children's Hand Chime Choir 2017-2018

PERMISSION TO ATTEND ACTIVITIES AWAY FROM MARY ESTHER UNITED METHODIST CHURCH

Mary Esther UMC

Sunday Service Schedule

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