Child's Name * First Name Last Name Child's Gender * M F Child's Birthdate * MM DD YYYY Parent's Name * Child's Grade * Preschool - 5th Grade Not of School Age Pre - K Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade Parent's Phone * Country (###) ### #### Parent's Email * Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Does the child have allergies? Any medical or learning disabilities? * Medical Release * I hereby authorize Faith Church Lubbock staff to call an emergency ambulance in case of accident or acute illness and to arrange necessary emergency medical and/or surgical care, in the event I am not immediately available. It is understood that a conscientious effort will be made to notify me (the parent or guardian) before such action will be taken. Any qualified physician called by Faith Church Lubbock Staff staff may treat and do whatever necessary for the health and well-being of my child. I also agree to accept full responsibility for all costs of any above-mentioned medical/surgical service. I Accept Thank you! Your form has been submitted. Child’s First Time Visitor Form
