Registration for Children's and Youth Ministries

Child's Name

Child's Date of Birth (mm/dd/yyyy)

Desired Atrium

Parent/Guardian Name(s)

Primary Email

This address will receive a confirmation email

Secondary Email

This address will receive a confirmation email

Primary Phone

Secondary Phone

Names and phone numbers of people who are authorized to pick up this child (other than parent/guardian(s)):

Person 1's Name & Number

Person 2's Name & Number

Person 3's Name & Number

Person 4's Name & Number

List any medical conditions, including severe allergies:

By checking the box below, I, the legal parent/guardian of the above mentioned child, hereby authorize and consent to the use of images or videos of my child, by Church of the Lamb (Penn Laird, Virginia) for purposes including but not limited to: promotional materials, printed publications, internet posts including social media, television, and other media sources. The church will not publish the name of the child. I do this with full knowledge and consent and waive all claims for compensation for use or for damages. I release Church of the Lamb (Penn Laird), its officers, trustees, employees, and agents from liability for any claims by me or any third party in connection with the use of the image of my child.

Yes No

Your typed signature is considered to be the same as your written signature.

Parent/Guardian Signature

Description

Please fill out this form and click submit.

Registration for Children's and Youth Ministries

Description

Please Fix the Following