Kidz Central Information Sheet
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Child's Name (Last, First) *
Address *
City *
State *
Zip Code *
Parent Home Phone Number *
Parent Cell Phone Number *
Parent Work Phone Number
Child Age *
Child Gender *
Date of Birth *
MM
/
DD
/
YYYY
T-Shirt Size *
Current School *
School Grade Last Completed *
Allergies  (Enter "None" if no allergies) *
Interests
Parent's Name *
Additional Emergency Contacts *
Medicines currently being taken by child *
Child's Doctor *
Hospital Preference *
Medical Insurance Company *
Medical Insurance Contract Number *
Medical Insurance Group Number *
Parent e-mail *
For VBS, who would your child prefer to be grouped with?
Where did you hear about us?
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By submitting this form, I, the parent or guardian of the above listed child, give my permission for participation in the ministry of CHRIST CENTRAL CHURCH (Southside, Alabama) and do release the church and its representatives and staff from all liability related to their participation.   In the event of an accident or injury, I hereby grant permission for the staff or representatives to administer necessary first aid, and/or to take the child to a medical facility for additional treatment.  I, the parent or guardian, will assume the responsibility of all medical bills, if any.  Should it be necessary for the child to return home due to medical reasons, disciplinary action, or otherwise, I will assume all transportation costs.  If there are any changes in the provided information, it is my responsibility to see that the staff is notified, and all information is updated.  An actual signature of this for will be required prior to participation.   *
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