HSMBC YOUTH AND CHILDREN

REGISTRATION FORM FOR YOUTH AND CHILDREN'S MINISTRY

ALL FIELDS WITH ASTERISKS (*) ARE REQUIRED.

Students Name: *

Birthdate: *

Grade: *

Zip Code: *

Address: *

Parent/Guardian's Name: *

Person(s) Authorized to Pick Up Child: *

Home Phone: *

Cell Phone: *

Emergency Contact Number: *

Email Address:

Does your child have any physical conditions that would restrict his/her participation in any activities?

If yes, please explain and give details

Do your child take any medication? If yes, please list.

Please list any allergies that your child has:

Are you a member of Harrison Street?

Yes
no

If not a member of Harrison Street where do you attend?

How will your child be transported to church?

I give my child permission to participate in Harrison Street Missionary Baptist activities for Youth/Children. *

I understand that my child will not be dismissed to any unauthorized person(s). I also understand that Harrison Street Missionary Baptist Church will not be held liable for any damages or injuries, which may be sustained. *

Please check if you agree

Parent's Signature: (Please Type Your Name) *

Date: *

Please check the ministries that your child will be attending:

Children's Wednesday Night Bible Study
Youth Wednesday Night Bible Study
Sunday School
Sunday's Children's Church
Nursery