Barrington DIG Form — BeFree Community Church

Barrington DIG & Childcare Registration Form

The information on this form is confidential and will only be used by adult child care supervisors to ensure your child remains safe and unharmed during your time with us. Please fill out the form in its entirety, noting the required questions.

Child's Name

First Name

Last Name

Birthdate

YYYY

Grade

Enter "Pre-K" for Nursery

Custodial Parent(s) / Legal Guardian

Enter name and phone info. If you are registering multiple children, and the address, pickup, and emergency information for each child is the same, you may leave the remaining fields blank when registering subsequent children.

Parent 1

First Name

Last Name

Phone

(###)

###

####

Parent 2

First Name

Last Name

Phone 2

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical

Please list any medical conditions we need to be aware of:

Allergies (Medications, food, etc.)

Pickup Information

Children may only be released to persons approved by the child's custodial parents or legal guardian. Please list below any additional persons (grandparents, aunts, uncles, siblings, etc.) who are generally authorized to pick up your child from their class.

Authorized to pick up my child

Name and relationship

NOT authorized to pick up my child

Name and relationship

Emergency Contact Information

In the event you are incapacitated during your time with us, unable to be located during an emergency, of it you are leaving the church property and unavailable while your child is under our care.

Emergency Contact Name

Emergency Phone

(###)

###

####

Family Doctor

Name

Doctor Phone

(###)

###

####

Image Privacy

May we have your permission for images, videos, and artist expressions of your child to be used and displayed by BeFree Community Church for purposes of sharing, celebrating, and training? Your child's last name will not be used in any public display.

I hereby give permission for photos or videos of my child to be used in church promotional materials.

I do not give permission for my child to be photographed or video recorded.

Emergency Evacuation Procedures

In the event that the fire alarm sounds, childcare workers will immediately remove your child to a safe location (usually the area behind the playground in back of the church). Parents must be certain to sign the sign-out sheet when retrieving children from the emergency pickup location. Failure to do so may cause emergency personnel to initiate a search for your child in a burning building, with potential injury or loss of life.

Parental Authorization

By submitting this form, I hereby authorize child care workers at BeFree Church to care for my child while I attend church functions. The contact information I have provided is accurate and I have read and understand the Emergency Evacuation Procedures. In the event that I am incapacitated or otherwise unavailable in an emergency, I hereby authorize emergency medical personnel to provide appropriate care for my child named above.

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