Child's Name_______________________________________________________

Date of Birth___________Age______ Grade as of Sep.2000__________________

Address______________________________________________ Zip__________

Home Phone Number______________________

Mother's Name____________________Work Phone__________Cell Phone_______

Father's Name_____________________Work Phone__________Cell Phone_______

Close Relative or Friend_________________________________________________

Address_____________________________________________________________

Home Phone______________________Work Phone__________Cell Phone_______

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Any known allergies requiring special attention__________________________________ _____________________________________________________________________

Any restrictions that should be observed_______________________________________ ______________________________________________________________________

Date of last Tetanus shot_____ Prescriptions taken on regular basis: _________________

Physician___________________________Phone_________Address_______________

Dentist_____________________________Phone_________Address_______________

Mother's Social Security Number_____________________________________________

Father's Social Security Number______________________________________________

Child's Social Security Number______________________________________________

Health Insurance Group____________________________________________________

Group Number___________________________________________________________

Ins urance Company Address_________________________________________________

Insurance Company Phone Number___________________________________________

I hereby grant permission for my child to participate in all of the activities of the church.

I hereby grant permission for my child to leave the church premises under the supervision of an adult for church related activities.

I hereby waive any claim against Kingwood United Methodist Church.

I hereby grant permission for the Minister, Staff Person, Youth Director, or authorized counselor to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following:

1. Attempt to contact parents or guardians through the numbers listed on this form.
2. Attempt to contact the child's physician.
3. If we cannot contact you or your child's physician, we will do any one or all of the following
   • (a) call another physician or paramedics,
   • (b) call an ambulance,
   • (c) have the child taken to an emergency hospital in the company of a staff member

4. Any expenses incurred under Number 3 will be borne by the child's family.
5. The church will not be responsible for anything that may happen as a result of false information given at the time of registration.

**Must be signed in the presence of the notary.**

____________________________________Date______________________

_{Signature of Parent or Guardian}

STATE OF TEXAS, COUNTY OF __________________________________

Before me, the undersigned authority, on this day personally appeared

______________________________________________________ known to me to be the person whose name is subscribed above, and acknowledged to me that he/she executed the same for the purpose therein expressed.

Sworn and subscribed before me this ______day of ________________

______________________________________

Notary Public of Texas (Seal)