Highland Park Baptist Church

CHILDREN’S MINISTRY / JR. HIGH MINISTRY ENROLLMENT & INFORMATION FORM

NOTE TO PARENTS/ GUARDIANS:

        In an effort to reduce paperwork and save time we have implemented the use of this enrollment form.  Once you have completed this form for your child/Children, Bro. Jeff will keep it on file for ONE YEAR (June to June).  During this year there will be no need for you to fill out “permission forms” for each event; you will be able to simply call & register your child for events that he/she will attend.             WE DO ASK THAT YOU COMPLETE THE FORM EACH YEAR SO THAT WE WILL HAVE THE MOST UP TO DATE INFORMATION.  THANK YOU!

PLEASE COMPLETE THE FOLLOWING:

FAMILY’S LAST NAME:  ________________________________________

CHILDREN:           ________________________________Birthday: __________Grade:_____

                                 ________________________________Birthday: __________Grade:_____

                                 ________________________________Birthday: __________Grade:_____

                                 ________________________________Birthday: __________Grade:_____

PARENT’S NAMES:           __________________________________________________

PHONE NUMBERS:       Please include ALL available numbers (home; work; cell; relatives; etc.)

(1) ________________________________ (2) ______________________________

(3) ________________________________ (4) ______________________________

(5) ________________________________ (6) ______________________________

Address: _____________________________________________________________________

Please note that this form will be used as a reference tool and will not be reviewed daily; please inform volunteers about SPECIAL NEEDS before each event

LIST ANY ALLERGIES WHICH CHILDREN HAVE (include child’s name beside allergy):

__________________________________________________________________________________________________________________________________________________________

PLEASE GIVE ANY SPECIAL MEDICAL INFORMATION (include child’s name):

__________________________________________________________________________________________________________________________________________________________

LIST CHILDREN’S REGULAR DOCTOR:

_________________________________________ (Phone) ___________________________

See reverse side

PLEASE PROVIDE US WITH YOUR BASIC HEALTH INSURANCE INFORMATION:

(Several of the camps that we attend require this information in case there were a medical emergency)

Name of Provider/Type of Insurance:           _____________________________________________

Group number: ____________________      Contract Number: _________________________

LIST OTHER PERSONS WHO HAVE PERMISSION TO PICK UP OR DROP OFF YOUR CHILD UNDER NORMAL CIRCUMSTANCES:

(Discuss this with your child so that they will know who they should ride with)

(1) _______________________________   (2) ______________________________

(3) _______________________________   (4) ______________________________

LIST ANYONE WHO IS NOT ALLOWED TO PICK UP YOUR CHILD:

(Please be sure that your child knows not to ride with this person)

(1)________________________________  (2) ____________________________

PLEASE GIVE ANY ADDITIONAL INFORMATION WHICH MAY BE NEEDED TO CARE FOR YOUR CHILD WHILE HE/SHE PARTICIPATES IN CHILDREN / JR HIGH MINISTRY ACTIVITIES.  (This form will be used as a reference tool and will not be reviewed daily; please inform volunteers about SPECIAL NEEDS before each event):

__________________________________________________________________________________________________________________________________________________________

I the undersigned parent/guardian give Jeff Eddie or his designee permission to seek medical treatment for my child if necessary*.  I also give Jeff Eddie or his designee permission to administer minor first aide as needed. 

I agree that neither the church, Bro. Jeff Eddie nor any chaperone will be responsible for accidents that may occur during ministry events.  I also agree that other organizations and individuals which provide activities for our group shall not be responsible for accidents that occur under normal circumstances/activities (examples of these groups include but are not limited to: Earle Trent Assembly, Shocco Springs Conference Center, Circle Y Ranch, etc.)

Further I give permission for my child to participate in all activities (unless otherwise stated on this form) during periods when he/she are involved in the ministry events.   I agree that participation may involve or include but will not be limited to: both indoor and outdoor activities, swimming & water activities, athletic or sporting events, travel on church vans, buses or in chaperone cars.  I understand that activities may be photographed or video taped and I give permission for my child’s photo/video to be used on displays such as bulletin boards, slide shows or password protected websites such as www.brojeff.com & www.hpbaptist.com.

I acknowledge that this permission agreement is valid from the date signed below.  I understand that it will be my responsibility to “verbally” inform chaperones of any special needs, medications or allergies prior to each event.

PARENT SIGNATURE: ________________________________ DATE:_________________

* Parents please know that you will be contacted if medical attention is required.  This permission is given to Bro. Jeff in the event that you can not be reached or can not arrive at the place where medical attention is being given.