Kids Registration Form | Living Word Christian Church

Child Information

Child's Name(Required)

First Last

Nickname (if applicable)

Gender

Male

Female

Birthday(Required)

Grade(Required)

This program runs September 1–August 31. Even if your child has completed a grade in school, in this program they are still considered in that grade through August 31.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent Information

Parent Name(Required)

First Last

Parent Primary Phone(Required)

Phone Type(Required)

Home

Mobile

Parent Secondary Phone

Phone Type(Required)

Home

Mobile

Parent Email(Required)

Additional Parent Name

First Last

Add'l Parent Phone

Phone Type

Home

Mobile

Add'l Parent Secondary Phone

Phone Type

Home

Mobile

Add'l Parent Email

Primary Contact Information

Complete this section ONLY if you are the primary contact for the child but not the parent/legal guardian (grandparent, caretaker, babysitter, etc.) Please also complete the Parent Information.

Primary Contact Name(Required)

First Last

Primary Contact Email(Required)

Relationship to Child(Required)

Primary Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Contact Phone

Phone Type

Home

Mobile

Primary Contact Secondary Phone

Phone Type

Home

Mobile

Emergency Contact Information

Emergency Contact Name

First Last

Emergency Contact Email

Emergency Contact Phone

Relationship to Child

Custodial Information

Is there any custodial information we should be aware of?(Required)

Yes

If yes, please explain

Church Information

Do you have a home church?(Required)

Yes

If yes, where?

Special Information

Any other interests, hobbies, or special information you would like us to be aware of?

General Permission

I hereby give permission for this child to participate in events and activities hosted by Living Word Christian Church and receive oversight from the authorized staff in charge, whose care the child has been entrusted into while attending and participating in these events and activities. (Note that all staff must be a member of Living Word Christian Church and must comply with a background check and any/all restrictions thereof.)

General Permission(Required)

Yes

Initial(Required)

Consumption Permission

I hereby give permission to Living Word Christian Church for this child to be offered snacks by authorized staff while in attendance. (Note that all Children’s Ministry classes are nut-free.)

Consumption Permission(Required)

Yes

Initial(Required)

Photo/Video Permission

I hereby give permission to Living Word Christian Church to record pictures or videos of this child while in attendance. I give permission to Living Word Christian Church to use these pictures of videos in church publications including, but not limited to, print publications, slideshows, church website, church social networks, etc. knowing that the child’s identity is kept anonymous.

Photo/Video Permission(Required)

Yes

Initial(Required)

Travel Permission

I hereby give permission to Living Word Christian Church for this child to ride in a vehicle designated by authorized staff, for the purpose of transportation to and from events and activities hosted by Living Word Christian Church. (Note that all drivers must be at least 21 years of age and produce a valid driver’s license and proof of insurance.) This permission does not include personal transportation, only that as part of the activity.

Travel Permission(Required)

Yes

Initial(Required)

Medical Permission

If emergency or required medical care is needed, I hereby give permission to Living Word Christian Church to such medical care as deemed necessary by medical care providers or the authorized staff.

Medical Permission(Required)

Yes

Initial(Required)

Medical Information

Please note all applicable allergies, medical conditions, mental conditions, health history, or medication information that would be necessary in an emergency:

Medical Condition(s)

Medication(s)/Dosage

Allergies (Food/Drug)

Physician(s)

Hospital

Date of last physical exam

Date of last tetanus shot

General health for the past two years

Excellent

Fair

Poor

Special Notes or Instructions

Release from Liability

Consent

I hereby hold harmless Living Word Christian Church, aka Word of Life Ministries Inc., and any of its employees, staff, members, and/or volunteers of any liability incurred at or as a result of attending events and activities hosted by Living Word Christian Church.

Release from Liability(Required)

Yes

Initial(Required)

Name(Required)

First Last

Date(Required)

Children's Ministry Registration 2022-2023

Child Information

Parent Information

Primary Contact Information

Emergency Contact Information

Custodial Information

Church Information

Special Information

General Permission

Consumption Permission

Photo/Video Permission

Travel Permission

Medical Permission

Medical Information

Release from Liability