Child Registration

Fill out this form to grant us consent to care for your child.

PARENTAL CONSENT AND PROMOTIONAL RELEASE FORM

Parents and legal guardians of minor children (18 years of age and under) are asked to complete this form. The information requested is designed to assist the church in providing for the safety of minors during church sponsored activities.

Child's First Name

Child's Last Name

Gender

Childs Date of Birth

Classroom

Grade if applies

Mailing Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Parent or Guardian's First Name

Parent or Guardian's Last Name

Relationship to Child

Parent or Guardian's Phone Number

Parent or Guardian's Email

In case we can't get ahold of the above contact, please list an additional contact. Thanks

Emergency Contact First Name

Emergency Contact Last Name

Relationship to Child

Emergency Contact Phone Number

Which additional family members have permission to drop-off or pick-up your child?

First Name

Last Name

Relationship to Child

Phone Number

First Name

Last Name

Relationship to Child

Phone Number

Allergies (Such as food, animal, pollen, or medication)

Other medical conditions we need to be aware of

I hereby consent to the use of any video, photographs, slides, audio, or any other visual or audio reproduction in which my child may appear by New Heights Church. I understand that these materials are being used for promotion of the children's ministry of New Heights Church, which includes recruitment and fundraising efforts. I release New Heights Church from any liability connected with the use of my child's picture or voice recording as a part of any promotional, recruitment, or fundraising event.

Do we have your permission? If Yes please sign below

Yes

Audio/video signature

I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all of the regularly scheduled activities of: Children’s Church programs of New Heights Church, 1522 S Grant Ave, York, NE 68467, from August, 2024 through August, 2025 including class parties & events, transportation to camp, and any other activities customarily associated with a children’s church program.

Participation signature

Date Input

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