Abbe Road Baptist Church

Child's Name (Required)

Child's Gender (Required)

Child's BIrthday (Required)

Child's Grade (Required)

The grade the child is entering in the fall.

ALLERGIES (Required)

Does your child have any allergies, food allergies, or dietary restrictions?

Parent/Guardian Name(s) (Required)

Live With

Phone Number (Required)

Where YOU can be reached while your child is at ARBC.

E-Mail Address (Required)

Home Address (Required)

Street Number, Street Name, City, State, and Zip Code

Emergency Contact (Full Name) (Required)

Emergency Contact Phone Number (Required)

FIRST AID AND EMERGENCY MEDICAL TREATMENT: (Required)

In the event my child needs first aid or emergency medical treatment as a result of any accident, injury, illness, or other health condition during the program or event, and if ARBC is unable to timely communicate with me or any alternate emergency contact, I hereby give permission for ARBC to provide or obtain such medical attention or treatment, including hospitalization, as ARBC deems necessary, and I agree to pay all fees and costs arising from such medical treatment. I give permission for all medical personnel to administer any needed medical treatment, including surgery and I agree to pay for such medical treatment. Select Yes if you agree to this statement.

Authorized Person(s) to Pick up Child (Required)

Who is authorized to pick up the child? Include phone number of not listed above.

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