Event Registration – Northwest Community Church

Northwest Community Church Permission Slip for Year-Round Activities

Child's Name *

First

Last

Birth Date

Age *

Sex *

Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Other Phone

Email Address *

Would you like to be added to our email list?

Father/Legal Guardian Name

First

Last

Mother/Legal Guardian Name

First

Last

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact Name

First

Last

Emergency Contact Phone

Does this child have any allergies, health problems that require medication or a special diet, or special considerations we should be aware of? *

If YES, provide a detailed explanation below. List name of condition, name of medication, medication schedule of doses, and/or other needs.

Allergies

Medications

Special Diet

Special Considerations

Can this child walk home alone? *

Approved Pick Up Persons *

Please list the names of individuals who have permission to pick up this child.

Medical Release Form *