Bronson First Baptist Pioneer Clubs Program
(Preschool and Grades K-5) Wednesdays: Dinner 5:30, Program 6:00 to 7:30
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Child's Name *
Date of birth: *
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Age: *
Parent or Guardian Name: *
Address: *
Medical Questions
Is your child presently being treated for an injury or illness? *
If you answered yes, please explain
Does your child have any allergies? *
If you answered yes, please explain
Does your child have a physical handicap or illness that would prevent him/her from participating in normal rigorous activity? *
If you answered yes, please explain
Consent and Authorization:
I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in the Pioneer Clubs Program conducted by the First Baptist Church of Bronson. I certify that my child is physically fit and adequately prepared to participate in this program.I do hereby agree to hold First Baptist Church of Bronson and its agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses and damages on account of injury to my child or property,which may arise in his/her participation in any associated church activities. *
Emergency Contact
Name *
Phone *
Transportation
Would you like your child to be picked up by the church van?
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If so, at what location would your child be picked up and dropped off?
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Social Media Consent
I give permission for my child to be photographed. *
I give permission for my child’s photos to be posted on First Baptist’s Facebook page. *
Sign and submit
By signing this form, I state that I have carefully read, understand, and agree to the contents of this form and understand that I am responsible for notifying the Church if any of this information changes. (Please Type Name Below) *
Please list any questions here. Thank you for registering for pioneer clubs!  
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