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Name of Child: |
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Date of Birth:
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Male or
Female:
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| Address: |
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| Phone #: |
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| E-mail (Parent): |
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| People authorized to pick up your child: (up to 4 names) |
Relationship to Child: |
Phone #: |
| 1)
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| 2)
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| 3)
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| 4)
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If needed, I allow GT Children's Ministry volunteers to change my child's diaper, or go with him/her to the washroom * Please note: No workers are allowed to go into the stall with your child. |
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I prefer you call my number each time my child needs a diaper change or needs to go to the washroom. |
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| To comfort my child, I suggest:
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| Does your child have any severe allergies?
(bee stings, food, penicillin, other drugs) |
Yes:
No:
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| If Yes, please explain: |
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| Is your child bringing any medication with him or her? (Antibiotics, ventilator, Ritalin) |
Yes:
No:
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| If Yes, please explain: |
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| Does your child have any physical, emtional, mental or behavioral concerns or limitations that our staff should be aware of? |
Yes:
No:
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| If Yes, please explain: |
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| PHOTGRAPH CONSENT |
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I hereby consent for the above named child to be photographed by GLAD TIDINGS CHURCH VICTORIA. |
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| 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. |
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| I acknowledge that all of the above information is current and correct: |
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| PARENT/LEGAL
GUARDIAN NAME:
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DATE:
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Security Code:
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