By signing my name below, I do hereby authorize the Woodstock Evangelical Covenant Church to seek emergency medical care for my child(ren) in the event of injury, accident or illness

Parent's Name (required)

Street Address (required)

City/State/Zip Code(required)

Phone Number (required)

Parent's Email (required)

Emergency Contact Name 1 (required)

Emergency Contact Phone 1 (required)

Emergency Contact Name 2 (required)

Emergency Contact Phone 2 (required)

Insurance provider and number(required)

May we have your permission to photograph your child(ren)? (required)
YesNo

Child (1) Name

Child (1) Age

Child (1) Grade

Child (1) Birth Date

Registering for... Please check all that apply (1)
Infant Nursery (0-24mo)Toddler Nursery (24-48 mo)Sunday SchoolChildren's ChurchAWANA

Medical/Health/Allergy Concerns (1)

I give permission for this child to be picked up by (1):

Child (2) Name

Child (2) Age

Child (2) Grade

Child (2) Birth Date

Registering for... Please check all that apply (2)
Infant Nursery (0-24mo)Toddler Nursery (24-48 mo)Sunday SchoolChildren's ChurchAWANA

Medical/Health/Allergy Concerns (2)

I give permission for this child to be picked up by (2):

Child (3) Name

Child (3) Age

Child (3) Grade

Child (3) Birth Date

Registering for... Please check all that apply (3)
Infant Nursery (0-24mo)Toddler Nursery (24-48 mo)Sunday SchoolChildren's ChurchAWANA

Medical/Health/Allergy Concerns (3)

I give permission for this child to be picked up by (3):