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Child’s Name *

First

Last

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Allergy(s) &/or Medical Condition *

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Email *

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Mother’s Name & phone *

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Father’s Name & phone *

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Emergency contact Name & phone *

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Who is authorized to pick up your child at dismissal? *

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I grant permission (check each box)

Authorization to publish pictures(without names)on website and other publications
In the event of illness or accident, I give permission for first aid to be administered where considered necessary by a person trained in first aid, if available, or medical treatment to be administered by a suitably qualified medical practitioner. I agree that neither Neapolis Church of Christ nor its volunteers assume any legal liability for injuries or other losses.
If I cannot be contacted and my child should require emergency hospital treatment, I authorize an adult leader to sign on my behalf any written form of consent required by the hospital. I understand that every effort will be made to contact me as soon as possible. I, the parent, assume all financial responsibility.

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