Children's Ministry Information Form

Phone

This field is for validation purposes and should be left unchanged.

Parent/Guardian's Name*

First Last

Select the Program for Which You're Registering*

Children’s Church

Vacation Bible School (VBS)

Children’s Revival Programming

Other (please let us know in the “Additional Information section”)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Emergency Contact Name & Relationship

Emergency Contact*

Email*

Cell Phone*

Home Church

Child Information

Child 1 – Name*

First Last

Child 1 – Date of Birth*

Last Grade Completed

Child 1 Shirt Size

Allergies or other medical conditions (ie. diabetes)

Any special circumstance we should be made aware of? (special needs or disabilities, and/or specific considerations?)

Child 2 – Name

First Last

Child 2 – Date of Birth

Last Grade Completed

Child 2 Shirt Size

Allergies or other medical conditions (ie. diabetes)

Any special circumstance we should be made aware of? (special needs or disabilities, and/or specific considerations?)

Child 3 – Name

First Last

Child 3 – Date of Birth

Last Grade Completed

Child 3 Shirt Size

Allergies or other medical conditions (ie. diabetes)

Any special circumstance we should be made aware of? (special needs or disabilities, and/or specific considerations?)

Child 4 – Name

First Last

Child 4 – Date of Birth

Last Grade Completed

Child 4 Shirt Size

Allergies or other medical conditions?

Any special circumstance we should be made aware of? (special needs, disabilities, medications?)

Additional Information

Additional Information- Please include any additional information below.

Photo/Video Release Statement

I understand that I or my child(ren) may be photographed and video-taped during this event. I hereby give to the Houston Berean Seventh Day Adventist Church my permission to use this material and release them from all liability and give the rights for publication of said materials for future promotions and advertising.

In accordance with the Photo/Video release Statement, I grant permission for my child(ren) to be recorded and/or photographed. Select Yes if you agree.*

Yes

Medical Liability Release

I am applying to participate in an activity of the Children’s Ministries Department as scheduled by the Houston Berean Seventh Day Adventist Church, and I will abide by all Texas Laws, rules, regulations, policies and directives of the officials of the Houston Berean Seventh Day Adventist Church. I understand that as an attendee, I consent and give the Houston Berean Seventh Day Adventist Church authority and permission to select a medical treatment facility, physician, and all necessary emergency medical care required in case of an accident or emergency illness for me/or my minor child. Note: Every effort will be made to contact me in case of an emergency; however, I will hold the Houston Berean Seventh Day Adventist Church forever harmless for supervising all required emergency care. I will be responsible for all payments of all treatments, hospitalization, anesthesia or surgery in respect to the emergency care on my behalf.

Physician

Physician Phone Number

Insurance Carrier

Group Number

ID Number

Volunteer

May we contact you about volunteering?

Yes

Final Authorization

By selecting I DO AGREE below, I attest that I am the legal parent/guardian for the child(ren) listed above and I understand that this form remains in effect until December 31, 2026 for all programming at Houston Berean Seventh Day Adventist Church. I also agree that all information provided above has been answered fully and correctly and I agree to the terms stated in this form.

Final Authorization*

I DO AGREE

Legal Parent/Guardian Name*

First Last

Parent's Date of Birth*

Today's Date*

Children's Ministry Information Form

Children’s Ministries Information Form

Child Information

Additional Information

Photo/Video Release Statement

Medical Liability Release

Volunteer

Final Authorization