Springfield Church of Christ
Child’s First Name
Grade Completed as of June 1, 2021
Emergency Contact Name (Someone other than the name above)
Emergency Contact Number
Emergency Contact Replationship
Additional Notes from Parent/Guardian (Include any additional people with permission to pickup your child or other information we should be aware of.)
Medical Consent - In the event of a medical emergency I give my consent for representatives of Springfield Church of Christ to seek medical attention for the child registered on this form.
Yes - I consent to medical treatment for my child
No - I do NOT consent to medical treatment for my child
I hereby grant permission to Springfield Church of Christ to use photographs or videos of the child registered on this form in print, electronic, online or other media.
Yes - I give consent to the photo/video release
No - I do NOT consent to the photo/video release
June 21-25, 2021 - 6:00pm - 8:30pm