GT Kids

GT GLOW KIDS - GRADES 1-5

Name of Child:			Date of Birth:
Age:		Male or Female:
Address:
Phone #:
E-mail (Parent):
E-mail (child):
Does your child have any severe allergies? (bee stings, food, penicillin, other drugs)			Yes: No:
If Yes, please explain:
Is your child bringing any medication with him or her? (Antibiotics, ventilator, Ritalin)			Yes: No:
If Yes, please explain:
Does your child have any physical, emtional, mental or behavioral concerns or limitations that our staff should be aware of?			Yes: No:
If Yes, please explain:

PHOTGRAPH CONSENT
I hereby consent for the above named child to be photographed by GLAD TIDINGS CHURCH VICTORIA.
Yes:	No:
Photographs may be used in publications produced by Glad Tidings Church Victoria. The publications may include, but are not limited to: brochures, bulletins, advertisements and websties. With the exception of our nursery/preschool name tag system, where children will not be identified by name.

I acknowledge that all of the above information is current and correct:
PARENT/LEGAL GUARDIAN NAME:			DATE:

	Security Code: