Scranton Road Bible Church Good News Kid Emergency Contact Info and Waiver

Contact Info

Student Name

Student Date of Birth

Student Current Grade

Student Current School

Parent/Guardian Name(s)

Parent/Guardian Cell

Parent/Guardian Email

This address will receive a confirmation email

Student Phone

Address

Emergency Information

Medical Conditions, allergies or physical restrictions: (if none, write none)

Emergency Contact

Emergency Contact Relationship to Child

Emergency Contact Phone

Permissions

Texting from SRBC Ministry Staff to Student Allowed

Yes No

Dismissal Procedure

I will pick up my child. Never allow them to leave alone or with anyone else. Children MUST be picked up from inside Scranton Road Bible Church. I give my child permission to walk home without an adult. I give my child permission to go home with the people named below.

If you allow your child to go home with an adult other than yourself, please list:

PHOTO RELEASE: Photos of your child(ren) may be taken at Scranton Road Bible Church and sponsored events throughout the year and may be used in church media such as fliers & presentations without personal information attached. Please indicate if you grant permission.

Yes No

I, the parent/guardian named on this form, give my consent for my child, named on this form, to participate in Scranton Road Bible Church's Good News Kids. I have completed the required form and understand all of the details in full.

By entering your full name, you are providing your digital signature in agreement with this document and its included contents of this page.

Todays Date

Description

Scranton Road Bible Church
3095 Scranton Road
Cleveland, Ohio 44113
(216) 861-7539

Sunday Mornings:
9:30am Sunday School
(ages 3 to adult)
10:45am Worship Service
(Nursery ages 0-2, Jr. Church ages 3-11)

Scranton Road Bible Church Good News Kid Emergency Contact Info and Waiver

Description

Please Fix the Following