Child/Teen Information Form

For safety reasons, we ask that all children and teens participating in VanChurch activities have an up-to-date Child/Teen Information Form on file.

Name of Child/Teen

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email (for teen)

Cell Phone (for teen)

(###)

###

####

Date of Birth

YYYY

Grade Placement for THIS School Year

(If you are completing this in the summer, please indicate which grade your child/teen will be in when the new school year starts. If your child is between the ages of 0 - 4 years old, please indicate how old your child will be on September 1.)

Gender

Allergies

Does the child/teen have an EpiPen or inhaler?

Is there anything else that would be helpful for us to know about your child/teen and his/her developmental, behavioral, emotional, or educational needs?

Siblings (please include name and age/grade)

Name for Parent/Guardian 1

First Name

Last Name

Relationship to Child/Teen

Cell Phone

(###)

###

####

Name for Parent/Guardian 2

First Name

Last Name

Relationship to Child/Teen

Cell Phone

(###)

###

####

My child may be released to...

VanChurch Children’s Ministry will only release children to a parent, guardian or designated adult. Teens are free to go whenever class is dismissed.

My child may NOT be released to...

As the parent/guardian of the child/teen listed on this form, I can verify that all the information on this form is accurate to the best of my knowledge.

Yes

I grant permission for my child/teen’s picture to be used within the VanChurch building and/or on the website.

Yes

Parent Signature (type your name below)

Today's Date

YYYY

Child/Teen Information Form

Thank you! Your Child/Teen Information form has been received!