Child InformationChild's Name(Required) First Last Birthday(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian InformationParent/Guardian 1 Name(Required) First Last Relationship to child(Required) Phone(Required)Phone Type(Required) Home Mobile Email(Required) Parent/Guardian 2 Name First Last Relationship to child PhonePhone Type Home Mobile Email Is there any custodial information we should be aware of?(Required) Yes No If yes, please explainAdditional Authorized PersonsA child will not be released to any individual unless we have your permission. Please list any person(s) other than yourself who are authorized to pick up your child. (Minimum age requirement of 18 years old.)Authorized Pickup Person #1 First Last Relationship to child PhonePhone Type Home Mobile Authorized Pickup Person #2 First Last Relationship to child PhonePhone Type Home Mobile Authorized Pickup Person #3 First Last Relationship to child PhonePhone Type Home Mobile Authorized Pickup Person #4 First Last Relationship to child PhonePhone Type Home Mobile Consumption PermissionI give permission to offer snacks/treats to this child while in attendance(Required) Yes No Photo ReleaseI hereby grant permission to Living Word Christian Church to record pictures or videos of my child while on the church property or at a church-sponsored event. I also give Living Word Christian Church permission to use these images or videos in church print and online publications including church websites and social networks knowing that their identity is kept anonymous.Please select your preference for the use of your child's photos:(Required) Permission granted for all purposes Permission granted only for in-house use (slideshows & various church presentations) Please DO NOT use any photos of my child for any purpose Medical HistoryMedical Conditions: Seizures Black-outs Heart Disease Chest Pain Diabetes Allergy: bee/wasp stings Allergy: food Asthma Recurring Headaches Other/details (Check all that apply)Other/Details List Any/All Allergies List special treatments/supplies needed (ie. Inhalers, EpiPen, etc.)Where will the needed supplies be? Is your child able to use this independently? Yes No How much assistance is necessary? Special Health Notes/InstructionsIs there any additional information you feel we should know about your child?Parent/Guardian AuthorizationName(Required) First Last Date(Required) MM slash DD slash YYYY Consent(Required) I agreeI consent to my son/daughter's attendance and participation in the activities of the Children's Ministry at Living Word Christian Church. I hereby hold harmless Word of Life Ministries, Inc., aka Living Word Christian Church, and any of its employees, staff, members, and/or volunteers for any incident that incurred at, or as a result of attending during the year documented on this form. If emergency or required medical care is needed, I hereby consent to such medical care as deemed necessary by medical car providers and the event person in-charge if I do not respond in a timely manner.