3rd Friday
Please fill out this form and click submit.
Child Name
*
Birthdate
*
Medical concerns/allergies
*
Food Requirements
Child Name
Birthdate
Medical concerns/allergies
Food Requirements
Child Name
Birthdate
Medical concerns/allergies
Food Requirements
Child Name
Birthdate
Medical concerns/allergies
Food Requirements
Parent/Guardian 1
*
Phone
*
Alternate Phone
Email
*
This address will receive a confirmation email
Text Messaging okay?
Please select one option.
yes
no
Parent/Guardian 2
Phone
Alternate Phone
Email
Text Messaging okay?
Please select one option.
yes
no
Individual authorized to drop-off/pick up child/children
*
Emergency information: (Parents will be the first point of contact)
Emergency contact 1
*
Phone
*
Emergency contact 2
*
Phone
*
Please fill out medical information below. If you have already completed this section, you do not need to fill it out again.
Doctor's Name and Phone Number
*
Dentist's Name and Phone Number
*
Insurance Provider
*
Insurance Provider's Phone Number
*
Policy Number
*
Group Number
*
Name of Policy Holder
*
I understand that 3rd Friday will take place at First United Methodist Church at 215 W. Works St
*
Please select all that apply.
yes
No
I understand that I will drop off my child/children by 5:00 PM and pick-up my child/children by 7:30 PM.
*
Please select all that apply.
yes
no
I give permission for my child/children to be photographed and/or videotaped
*
Please select all that apply.
Yes
No
In the event of an emergency, I understand that every effort will be made to contact me as quickly as possible. I hereby authorize an adult leader of this activity to act as agent for me to consent to any medical, dental, or surgical treatment necessary by a licensed medical professional. I acknowledge that I am financially responsible for any emergency medical or dental costs.
*
Please select all that apply.
Yes
No
Parent/Guardian signature
*
Date
*
Submit
Description
Please fill out this form and click submit.
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