Kids Ministry & Nursery Registration 2022-2023

Child's First and Last Name

Child Information

Child's Birthdate

Child's Age as of September 1, 2022

Child’s Grade as of Fall 2022

Father/Male Guardian Information

Father/Male Guardian

Father/Male Guardian Address

Father/Male Guardian Phone

Father/Male Guardian Email

This address will receive a confirmation email

Mother/Female Guardian Information

Mother/Female Guardian Name

Mother/Female Guardian Address (if different from above)

Mother/Female Guardian Phone

Mother/Female Guardian Email

This address will receive a confirmation email

Medical History

NOTE: Neither Clifton Baptist Church nor its caregivers will administer prescription or over-the-counter medications of any kind, in any circumstances, with the exception of epinephrine injectors. If an epinephrine injector is necessary for your child, please contact the Nursery Director or Kids Ministry Director. It will be the parents’ responsibility to properly train the caregivers in the proper administration of an epinephrine injector.

Please provide any significant medical history, psychological history, or other pertinent information that will be useful or necessary in caring for your child or in an emergency. Please be as complete as possible.

Please list any medically significant allergies to medication or food:

Dietary restrictions. Please state whether for medical or other reasons:

Please list any current medications your child is taking:

Does your child carry an Epi-pen?

Yes No

Is your child up-to-date on their Tetanus booster?

Yes No I don't know

Date of last Tetanus booster (if applicable)

Physician's Name

Physician's Phone

Emergency Notification

If I am unavailable in the case of emergency please notify:

Emergency Contact's Name

Emergency Contact's Phone

Emergency Contact's Alternate Phone

Pick Up and Drop Off with Nursery & Kids Ministry

Only parents will be allowed to drop their children off and pick them up from the Nursery or Children’s Ministries. However, should the parents wish for someone else to drop off or pick up their child(ren), the parents of children ages 0-5th grade must obtain the consent of the Nursery Coordinator and/or Children’s Ministries Director and return either a completed Children’s Ministry Child Release Form (if they desire an older sibling to drop-off/pick-up a younger sibling, or give self-check-in privileges to children 3rd grade and above) or a completed Permission for Alternate Drop Off/Pick Up Form prior to the parent’s absence, should the parents desire someone other than themselves to bring their child to church. These forms are available at the Nursery counter or Children’s Ministry Desk.

Permission

I do hereby give permission for my above-named child to participate in ALL programs and events sponsored by Clifton Baptist Church, of Louisville, Kentucky, whether at church or off-site and transportation to and from any programs and events.

I understand that, in the case of an emergency Clifton Baptist Church, employees, agents, members and/or sponsors will make every effort to contact me and/or the contact person named on the reverse side; however,

Should the named contact person, or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for Clifton Baptist Church employees, agents, members, and/or sponsors to obtain emergency medical attention in case of sickness or injury, to my child, up to and including hospitalization and I understand that I am responsible for any expenses incurred.

Should the named person or myself be unavailable to make decisions regarding my child’s care, I do hereby grant permission for an attending physician or hospital to perform whatever care is deemed necessary for the welfare of my child.

Hold Harmless

I hereby release, absolve, indemnify, hold harmless, and forever discharge Clifton Baptist Church, its employees, agents, organizers, sponsors, members, or any supervisors appointed by them from any and all claims, demands, actions or cause of actions, past, present, or future arising out of injury or damage to my child while participating in any program or event, or from any check-in/check-out policy.

I assume all risks and hazards incidental to the conduct of the programs or events and check-in/check-out policy. In case of injury to my child, I hereby waive all claims against Clifton Baptist Church, its employees, agents, organizers, sponsors, members, or any supervisors appointed by them.

***If you choose to later revoke this permission/release it must be done in writing. ***

Parent/ Guardian Electronic Signature

By entering your full name in this field you agree to the above terms. You are also agreeing that this electronic signature is the same as a handwritten signature for the purposes of validity, enforceability and admissibility.

You may opt out of an electronic signature by requesting a paper copy of this document from the sending party, which you can then sign and return in person.

Parent/ Guardian Electronic Signature

Date of Signature

Kids Ministry & Nursery Registration 2022-2023

Description

Please Fix the Following