Wee (Weekday Early Education) School Registration Form

Contact and Personal Information

Child's Name

Birthdate

Gender

Male Female

Address

Mobile Phone

Home Phone

Custodial Parent(s) / Guardian(s) Name(s)

Home Address (if different)

Health Plan Carrier

Name of Insured

Relationship to Policyholder

Policyholder / Insurance ID#

Family Doctor

Office Phone

Emergency Contact

Relationship to Participant

Mobile Phone

Home Phone

List any court-appointed restrictions

Those authorized to pick up my child are (Must list first/last names & relationship to you)

Photo Release

I hereby grant permission to Mt. Harmony Baptist Church's WEE Program to use my child's photograph(s) on its Web site, private Facebook page, or in other official church printed publications without further consideration.

I acknowledge the church has the right to crop or treat the photograph(s) at its discretion.

I also acknowledge that the church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date.

I also understand that once my image is posted on the church's website, the image can be downloaded by any computer user, anywhere in the world.

Therefore, I agree to indemnify and hold harmless the church, its trustees, pastor, associate pastors, deacons, its members and designees from any claims arising out of the use of my photograph(s).

The church reserves the right to discontinue use of any photograph(s) without notice.

I understand the photo release statement above, and I grant Mt. Harmony Baptist Church permission according to the terms listed above to use my child's photo on the Private Facebook Page.

Yes No

I understand the photo release statement above, and I grant Mt. Harmony Baptist Church permission according to the terms listed above to use my child's photo on the Church's Website and in other church marketing material.

Yes No

Medical Information

Child's Name

Does child have any of the following conditions: (If "yes", please explain)

Allergies

Yes No

Allergies?

Heart Condition

Yes No

Heart Condition?

Diabetes

Yes No

Diabetes?

Other Yes No

Other?

Is the child subject to: (If "yes", please explain)

Headaches

Yes No

Headaches?

Seizures

Yes No

Seizures?

Motion Sickness

Yes No

Motion Sickness?

Fainting

Yes No

Fainting?

Upset Stomach

Yes No

Upset Stomach?

Other

Yes No

Other Explained

Does the child have a reaction to: (If "yes", please explain)

Bee Sting

Yes No

Bee Sting Explained

Penicilin

Yes No

Penicilin Explained

Other Drugs

Yes No

Other Drugs Explained

Poison Ivy, Oak, Sumac

Yes No

Poison Ivy, Oak, Sumac Explained

Peanuts

Yes No

Peanuts Explained

Other

Yes No

Other Explained

Does the child have any condition that would prevent him/her from participating in any of the activities of this program?

Yes No

If yes, please explain

Does the child take any prescription medications?

Yes No

If yes, please list medications

Does the child have any sight or hearing impairments?

Yes No

If yes, please explain

Does the child wear contact lenses?

Yes No

Does the child wear hearing aids?

Yes No Option

Blood type

Date of last tetanus shot

Please indicate anything else that the caregivers should know about the child.

(Nursery-age children) Is there anything that is especially comforting to your child? For example: a favorite blanket, a song, a pacifier, a story, a particular way of being held, etc.

Wee (Weekday Early Education) School Registration Form

Description

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