Child's Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Birthdate *

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Phone Number (cell preferred) *

(###)

###

####

Emergency Contact Name *

The name of the person you would like us to contact in the event of an emergency and the parent/guardian cannot be reached

First Name

Last Name

Emergency Contact Phone Number *

The phone number you would like us to contact in the event of an emergency and are unable to reach the parent or guardian

(###)

###

####

Photos/videos release for Calvary Baptist Church use only *

Yes

No