Salt & Light Registration | Burr Oak Church Albion, IN

Name (Required)

Email Address (Required)

Salt & Light Kids Club 2023-24

PERMISSION SLIP / EMERGENCY FORM Please complete this form that will accompany your child for the '23-'24 season. This information is necessary should we need to contact you. No student will be allowed to attend without this form being completed and signed by the parent or legal guardian. The information on this form is considered confidential.

Permission is granted for (Students Name) to attend Burr Oak's The Salt & Light Kids Club located at Burr Oak Church 501 W 200 S Albion, IN 46701260-636-3291 for the 2023-24 season. (Required)

Parent/Guardian Information

Name (Required)

Your Address (Required)

Your Phone Number (Required)

Emergency Contact (Required)

In the event of an emergency, who do we contact? Phone number?

Medical Information

Please provide the information requested below, as it may be needed in case of an emergency. This information does not modify the information on the emergency card.

Allergies or Medical Info (Required)

Does your student require (Check What Applies): (Required)

ANY MEDICATION CURRENTLY TAKEN: (Type of medication and time of administration): (Required)

Primary Contact

If different from above.

Emergency Contact

If different from above.

Student's Physician (Required)

Phone Number

Student's Dentist

Phone Number

TO ANY DOCTOR OR HOSPITAL:

I hereby authorize the release of my child’s pertinent medical information to the appropriate professional staff. I give permission to the physician or hospital to secure treatment for him/her and to order medications, injections, anesthesia, or surgery for my child, as named above, in case of emergency. The signature below constitutes authorization to perform any necessary treatment for my child during this field trip.

Health Insurance Information:

Company Name: (Required)

Policy #: (Required)

Group #: (Required)

Church Transportation

At times it becomes necessary to use private vehicles or the church-owned van to transport students to and from Burr Oak Baptist Church children/youth activities. When this occurs, Burr Oak Baptist Church requires that a parent/guardian of the student sign the Transportation Release Consent Form. This form operates as general consent for the transportation of students to and from church connected activities. By signing this form, I hereby release Burr Oak Baptist Church, as well as its directors, coordinators, employees, or other agents from all liability or damages for any and all injuries arising from the negligence of any of the above while traveling to an activity via private vehicle or church van.

Does your child(ren) need regular weekly transportation to and from Burr Oak? (Required)

I give general consent for the transportation of my child, by the employees/volunteers of Burr Oak Baptist Church. (Required)

I give general permission for my child to attend church related field trips. (Required)

I give Burr Oak Church permission to take and use pictures/video of my child(ren) for church related events. (Required)

Name (Required)

Date (Required)