Emergency Contact Card

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Vacation Bible School

Beatitude Living – Evening

Vacation Bible School

Circle of Prayer

Women’s Summer Bible Study

Contact

Worship with Us

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Name: Women’s Summer Bible Study
Start: 2018-06-28T19:00:00-04:00
End: 2018-06-28T20:30:00-04:00
Location: The Pit

Parents, the safety of your children while they are in our care is incredibly important to us. We ask that all families have current emergency contact information on file with us.

This form is for families with children in the Children’s Ministry (required for ages four – 5th grade) and Student Ministry (6th – 12th grades). If you have an infant or toddler in our nursery program, please fill out a separate Nursery Care Card today.

To avoid any confusion, please fill a separate form out for each child.

Is this child in the Student Ministry or Children's Ministry?*
- Student Ministry (6th - 12 grade)
- Children's Ministry (age four - 5th grade)
Student or Child's Name*
First Last
Preferred Name/Nickname*
Date of Birth*
MM
DD
YYYY
Siblings
Click the + sign to add more rows.
Name Age
Mother's Name*
First Last
Cell Phone*
Mother's Home Phone
Work Phone
Father's Name*
First Last
Cell Phone
Home Phone
Work Phone
Family's Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Enter Email Confirm Email
Are you and your family members or friends of Signal Pres?
- Members
- Visitors
Child's Known Allergies*
Medications*
Emergency Contact*
Please list two people who can serve as an emergency contact if a parent is not available.
Name Phone
Emergency Contact*
(not a parent)
Name Phone
Emergency Medical Information*
Pediatrician Phone Number Preferred Hospital
Photo Permission*
- Yes, I give permission for the leaders of Signal Pres to photograph my child for church purposes.
- No, I do not give permission for the leaders of Signal Pres to photograph my child for church purposes.
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I, the parent/guardian of child being registered, authorize the adult leaders of Signal Mountain Presbyterian Church, to act as my agent to consent to emergency treatment. I understand that every attempt will be made to contact the parent/guardian in the event of any emergency. I therefore assume all responsibility for decisions so made, and the emergency care or treatment secured for my child.
Disclaimer*
- Please check that you have read and agree to the above disclaimer.
Name
This field is for validation purposes and should be left unchanged.

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