Child's Information

Last Name (required)

First Name (required)

Gender(required)
MaleFemale

Date of Birth (required)

Church Presently Attending (required)

(Please check all that apply)

Sunday SchoolKids’ WorshipChildren’s ChoirAwanaVBS

Parent or Guardian Information

Last Name (required)

First Name (required)

Relationship to child (Please select one) - NOTE: Must be a legal relationship of the child

ParentGuardian

Home Address (required)

City (required)

State (required)

Zip (required)

Home Phone (required)

Mother's Cell Phone

Father's Cell Phone

Primary Email (required)

Alternate Email

Medical and Emergency Contact Information

Medical Insurance Company

Policy Number

Group Number

Name of Parent/Guardian who is policy holder

Emergency Contact Name (Other than the one listed above)

Home Phone (required)

Cell Phone

Other Phone

Child Release Information

Please list individuals authorized to pick up your child from CBC Children’s Ministries, including responsible siblings (Name only):

Name:

Name:

Name:

Name:

Self Release (Grades 3-6 only) - (Children will leave class on own & meet parents)

YesNo

Activity Information

Please list any and all activites that you DO NOT want your child to participate in

Important Notices and Information

For the safety of all children, we reserve the right to limit this ministry to any child based on the ability of Calvary Bible Church staff and/or volunteers to properly ensure his/her safety and the good health of all involved due to their special physical, mental, behavioral or emotional needs and the limited resources available within this facility. You will be contacted and asked to immediately attend to your child in the event of the following: bathroom or toileting accident, illness, injury, behavioral difficulty or any other issues deemed appropriate.
I agree

Please list ALL medication (over the counter or by prescription) that your child is currently taking along with the dosage, quantities and times. Please be specific:

Past or current special needs/health issues/allergies/behavioral diagnosis that could be important for the physician, staff or volunteer member to know for proper diagnoses and treatment, especially pertaining to the information provided above or any other information you deem vital:

MEDICAL AND LIABILITY AGREEMENT:

In consideration of the child’s participation in ministries and activities, as well as transportation to and from ministries and activities of Calvary Bible Church located at 603 Wilson Ave, Hanover PA 17331. I, individually and on behalf of any other parent or guardian of the child named agree to release, indemnify, defend, and forever discharge Calvary Bible Church, the board of elders, employees, paid staff, volunteer staff, and all representatives of and from any and all claims, losses, injuries, (up to and including death), demands, rights, and causes of action which may result from participation of the child. I/We know that children may be injured, sometimes seriously, up to and including death. I/We certify that the child named is physically and medically able to participate in the activities (except as noted) and related activities to the best of my/our knowledge, information, and belief. In the event of an emergency, every effort will be made to immediately contact the parent or guardian at the phone number(s) listed. If I/we cannot be reached at the phone number(s), I/We give permission to the physician selected by Calvary Bible Church to hospitalize, secure proper treatment for and order injection(s), anesthesia, or surgery for the child as the physician(s) sees fit. I/We release Calvary Bible Church, and their employees, volunteer and paid staff, affiliates, representatives, directors, elders and officers for any medical treatment provided hereunder. I/We agree to be completely responsible for any and all treatment and related costs for medical and dental services provided pursuant hereto. I/We give our permission to Calvary Bible Church to use such photos or recordings and release and hold harmless Calvary Bible Church for any action taken as stated herein, from any and all claims, losses, or injuries which could or may result from such activities, including from any acts of negligence or carelessness related thereto. For a chance or opportunity that the church insurance may come into play with or without your insurance, a doctor’s visit must be on file. In the event of any injury, a doctor needs to be seen within 90 days of the injury/accident.

Appropriate photographs and/or video recordings may be taken of the child while participating in any related activities. These photos and/or video recordings may be published in Calvary Bible Church’s ministry materials such as in/on bulletin boards, flyers, mailers, web site, in-house video and the like with no personal information listed.

Published on Calvary Kids Facebook page

Livestreaming on Calvary’s YouTube

Please use your cursor or finger and sign in the box below.