Child Registration | Lewisport Baptist Church

Name of Parent Completing Form*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Parent's Cell Phone #*
Emergency Contact*
First Last
Emergency Contact Phone*
Emergency Contact Relationship*
I am registering my child for:
(check all that apply)
- 5th & 6th Grade Lock-In (May 17)
- 2019 VBS (June 17-21)
- 2019-2020 Wed. Night Shine Activities
- Sunday School at 9:30 a.m.
- Sunday Morning Children's Church at 10:45 a.m. (ages 3-5 years)
- Nursery (up to age 3) at any time
- Special events as they arise during the year
# of Children You Are Registering*

Child #1
Child #1 Name*
First Last
Child #1 D.O.B.*
Date Format: MM slash DD slash YYYY
Child #1 Grade Completed*
Child #1 School
Child #1 Food Allergies
Child #1 Medicines
Child #1 Other Notes
Child #2
Child #2 Name
First Last
Child #2 D.O.B.
Date Format: MM slash DD slash YYYY
Child #2 Grade Completed
Child #2 School
Child #2 Food Allergies
Child #2 Medicines
Child #2 Other Notes
Child #3
Child #3 Name
First Last
Child #3 D.O.B.
Date Format: MM slash DD slash YYYY
Child #3 Grade Completed*
Child #3 School
Child #3 Food Allergies
Child #3 Medicines
Child #3 Other Notes
Child #4
Child #4 Name
First Last
Child #4 D.O.B.
Date Format: MM slash DD slash YYYY
Child #4 Grade Completed
Child #4 School
Child #4 Food Allergies
Child #4 Medicines
Child #4 Other Notes
Child #5
Child #5 Name
First Last
Child #5 D.O.B.
Date Format: MM slash DD slash YYYY
Child #5 Grade Completed*
Child #5 School
Child #5 Food Allergies
Child #5 Medicines
Child #5 Other Notes

Medical Information and Release
The undersigned hereby gives permission for our (my) aforementioned child/children to ride the bus or van to and from activities sponsored by the Lewisport Baptist Church and to participate in all children’s activities during the 2019-2020 school year (July 1, 2019-June 30, 2020).

We (I) authorize an adult, in whose care the minor has been entrusted, to transfer my child to the emergency room if a parent or emergency number cannot be contacted: to consent to an X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The under signed shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for our (my) child to return home due to medical reasons, the undersigned shall assume transportation costs.

The undersigned does also give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Lewisport Baptist Church.
Hospital Insurance*
- Yes
- No
Insurance Company
Policy #
Doctor
Doctor Phone #
Hospital Preference
E-Signature*
- By checking this box I acknowledge that I have read the above medical release and that all of the information contained in this registration form is true to the best of my knowledge.
Please Type Your Full Name*
Signature Date
Date Format: MM slash DD slash YYYY
Photo/Video Release
I also give permission for Lewisport Baptist Church to use any photographs or videos taken of my child in, but is not limited to: newspaper, web pages, social media, television, etc.
E-Signature*
- By checking this box I acknowledge that I have read and agree to the above photo/video release.
Please Type Your Full Name*
Signature Date
Date Format: MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Register Your Child

Step 1 of 3

Child #1

Child #2

Child #3

Child #4

Child #5

Medical Information and Release

Photo/Video Release

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