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form-childhood

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Please fill out this form to allow us to teach & care for your children in our Preschool Dept. while you go to our Adult Worship Services.
This consent shall remain in effect until...(write in date or "indefinitely")

Your name

PARENT/LEGAL GUARDIAN(S)

Father/Guardian 1

Mother/Guardian 2

Address


Email Address

CONTACT NUMBERS

Father/Guardian 1
Home Phone
Cell Phone

Mother/Guardian 2

Home Phone
Cell Phone

Other
Home Phone
Cell Phone

ADULTS (18 OR OLDER) AUTHORIZED TO PICK UP MY(OUR) CHILD(REN)
Will be required to to show photo ID at time of pick up.

Adult 1

Adult 2

Adult 3

Adult 4

MEDICAL/BEHAVIORAL INFORMATION
List for each child

Child One

DOB

Allergies (drugs/food)

Chronic Illnesses/Conditions

Regular Medications

Other Instructions or Comments

Child 2

DOB

Allergies (drugs/food)

Chronic Illnesses/Conditions

Regular Medications

Other Instructions or Comments

Child 3

DOB

Allergies (drugs/food)

Chronic Illnesses/Conditions

Regular Medications

Other Instructions or Comments

OTHER AUTHORIZATIONS
My child(ren) has(have) permission to participate in the ministries of Riverview Baptist Church.

DOB

My child(ren) has(have) permission to have their photographs in publications of Riverview Baptist Church.

DOB

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