*Denotes Required Field * Title Parent/Guardian 1 * First Name * Last Name * Email Home Phone ( ) - Cell Phone ( ) - Parent/Guardian 2 First Name Last Name Email Home Phone (if different from above) ( ) - Cell Phone ( ) - Emergency Contact (If Parent Unavailable) * First Name(s) * Last Name * Relation * Phone ( ) - Alternate Phone ( ) - Child 1 * First Name * Last Name * Date of Birth (MM/DD/YYYY) School * Grade Entering Please select an option 7 8 9 10 11 12 Cell Phone ( ) - Email Allergies/Medical Conditions/Special Needs Child 2 First Name Last Name Date of Birth (MM/DD/YYYY) School Grade Entering Please select an option 7 8 9 10 11 12 Cell Phone ( ) - Email Allergies/Medical Conditions/Special Needs Child 3 First Name Last Name Date of Birth (MM/DD/YYYY) School Grade Entering Please select an option 7 8 9 10 11 12 Cell Phone ( ) - Email Allergies/Medical Conditions/Special Needs Please select the desired responses Authorization for Treatment I hereby give permission to the medical personnel selected by McKernan Baptist Youth Ministry and McKernan Baptist Church to provide medical care in the best interest of my son/daughter in case of a medical emergency. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by McKernan Baptist Youth Ministry and McKernan Baptist Church to treat my son/daughter, including hospitalization, if necessary. * Please select one. Please select an option YES NO Photo Release I hereby give permission to McKernan Baptist Youth Minstry and McKernan Baptist Church to use photographs of my son/daughter and to display and/or copy the works of my son/daughter for the sole use of McKernan Baptist Youth Ministry and McKernan Baptist Church. I understand that these items may also be posted on the church website, official Church social media pages, or included in church publications. * Please select one. Please select an option YES NO Transportation Release I hereby give permission to McKernan Baptist Youth Ministry, Pastors of McKernan Baptist Church, and all Youth Ministry Team Leaders to transport my son/daughter during any and all McKernan Baptist Youth Ministry activity and ministry visits by using their own personal vehicles, public transportation and vehicle rentals. * Please select one. Please select an option YES NO * Please list any individuals NOT authorized to pick up your child from youth events. If none, please enter "NONE". * I agree that the information on this form is current and accurate and by checking this box, I agree to the terms of the above agreements. * This form was filled out by:
