Parent's Information
 Name - First   Last 
 Address 
 City State   Zip
 Phone  Email
 Emergency Contact
 Emergency Contact's Phone

Children(s) Information

 Child's Name  DOB  
 Rising Grade PreK 1st 2nd 3rd 4th 5th 6th Other Sex of Child
 Allergies/special concerns

 
 Child's Name  DOB  
 Rising Grade PreK 1st 2nd 3rd 4th 5th 6th Other Sex of Child
 Allergies/special concerns


 Child's Name  DOB  
 Rising Grade PreK 1st 2nd 3rd 4th 5th 6th Other Sex of Child
 Allergies/special concerns

 If more than 3 Children, please enter names and ages of additional children in the notes field at the bottom of this page.

Are you willing to volunteer? Yes     No

 Medical Information
  Doctor's Name:
  Doctor's Phone:
  Medical Insurance Company:
  Medical Insurance ID Number:
  Notes
 

Medical Release:  Our procedure in case of emergency is: 1) to render first aid; 2) call for professional help if necessary; 3) call home or emergency contact.  In some cases, attempts to contact you or your emergency contact could delay treatment.  Only after reasonable efforts have been made to contact you will we call your doctor, and only when deemed necessary will your child be taken to the hospital. 

Burke United Methodist Church and the adults in charge have my permission to take action to ensure my child’s well being.

  Acknowledged (Type yes to acknowledge the medical release)