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CBC Activity Participation Agreement
Community Baptist Church
7832 W Mt Hope Hwy. Grand Ledge MI 48837
Pastor Timothy Jackson & Pastor Joe Jackson
* Indicates required question
Email
*
Record my email address with my response
Please provide the name of the event
*
Your answer
Please enter today's date.
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MM
/
DD
/
YYYY
Your Child's or Children's Full Name(s)
*
Your answer
What is the parent's or legal guardian's name?
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Your answer
What is your address?
*
Your answer
What is your phone number?
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Your answer
What is the parent's or legal guardian's email address?
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Your answer
Please provide an emergency contact.
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Your answer
What is the emergency contact's phone number?
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Your answer
Child's Age
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4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Required
Child's Grade
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Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10 Grade
11th Grade
12th Grade
Required
Are you a member or regular attender of Community Baptist Church?
Yes
No
Clear selection
Please let us know if your child has any allergies or medical conditions.
*
Your answer
Is the emergency contact authorized to approve medical treatment?
*
Yes
No
Is the child covered by personal or family medical insurance?
*
Yes
No
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