Special Needs Registration
Please fill out this form and click submit.
Child/Adult Name
*
Email
*
This address will receive a confirmation email
Phone
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Parent(s)/Guardian(s) Names
*
Allergies or Food Restrictions:
*
Diagnosis
*
Medicine
*
Hygiene(bathroom) Capabilities
*
Behavioral Support Needs
*
What makes me uncomfortable
*
What makes me comfortable
*
Emergency Contact (if parents can't be reached)
*
Emergency Contact Phone
*
Additional Helpful Hints
*
Declaration of Consent
By checking yes to the items you are consenting to the statement. By checking no you are not consenting to the statement.
I give permission to First Christian Church to make necessary decisions for medical treatment if parents/guardian are unable to be reached.
*
Please select all that apply.
Yes, I agree
No, I do not consent
I give First Christian Church permission to use my child's picture in presentation, church publication, church website, and Facebook page.
*
Please select all that apply.
Yes, I give permission
No, I do not give permission
I release First Christian Church, all staff and volunteers from all liability for any additional illness or injury to my child, and for any accidental damage or destruction of my child's property during an activity at church.
*
Please select all that apply.
Yes, I agree
No, I do not agree
I give permission for my child to have a snow cone.
*
Please select all that apply.
Yes, enjoy
No, not a good idea
Can we discuss
Any additional information you wish to let us know.
Submit
Description
Please fill out this form and click submit.
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