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Playschool 2018-19 on Thursday, September 6, 2018 @ 9:00 AM

100.00
*Gender:
*Birthdate:
*Age as of September 1:
*Parent's Relationship to each other::
Child lives with: (Please check all that apply.):
If other, please explain:
*Are you a member of Sagemont Church?:
Father's Name:
Father's Address, if different than child's:
Father's Work Phone #:
Father's Cell Phone #:
Father's Email:
*Mother's Name:
Mother's Address, if different than child's:
*Mother's Work Phone #:
*Mother's Cell Phone #:
*Mother's Email Address:
In case parents cannot be reached, please list at least two local people who have permission to assume responsibility for your child in case of illness or emergency:
*Contact #1 Name:
*Contact #1 Relationship to Child:
*Contact #1 Address:
*Contact #1 Home Phone #:
*Contact #1 Cell Phone #:
*Contact #2 Name:
*Contact #2 Relationship to Child:
*Contact # 2 Address:
*Contact #2 Home Phone #:
*Contact #2 Cell Phone #:
We/I consent to and approve the use of video and photographs of my child for ministry purposes by Sagemont Church of Houston, Texas, with the understanding that such media use will not be identified with my child’s name. I grant to Sagemont Church the perpetual rights to use and re-use such photographs for printed and/or electronic formats including but not limited to brochures, newsletters, and websites material including the closed content Playschool Facebook page:
*Media Consent::
Please list any medications taken regularly by your child:
Please list any allergies or other medical conditions:
*The above information is correct as of (date):
In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize Sagemont Church Staff to take my child to an Emergency Room, or to the following physician or his/her associates, for medical care :
*Dr. Name:
*Dr. Address:
*Dr. Phone #:
I give consent for any and all treatment deemed necessary by the attending physician. I understand that a representative of Sagemont Church will contact me immediately. I release and hold harmless Sagemont Church and its representatives from any claims or liability for authorizing medical care and transportation for my child. (Please bring a copy of insurance card.):
*Medical Consent::