Kids & Youth Registration Form (Both locations) • Coast Community Church

Campus

Please select a Campus *

Bensville

Tumbi

Childs Details

First Name *

Last Name *

Gender

Date of Birth *

School Grade *

Home Address

Home Address Line 2

Home City

Home State

Home Zip Code

Email Address

Tip: Your Childs email address (please leave blank if not applicable)

Mobile Number

Tip: Your Childs mobile number (Please leave blank if not applicable)

Other Information

Allergies or additional needs

Details of allergies or additional needs *

Tip: Details of allergies or additional needs (please include instructions on how to treat/manage need)

Custody Arrangements/issues

Details of custody arrangments/issues *

Parent/Guardian/Emergency Contact Details

Emergency Contact *

Emergency Contact # *

Emergency Contact Email *

Relationship to child *

Permission

Permission to seek medical assistance in an emergency *

Yes

Tip: I give permission for Leaders to seek medical assistance for my child in the event of an emergency, including transporting by car to hospital/doctor or by ambulance.

Permission for photos and video *

Yes

Tip: I give permission for photo's and video recordings to be used in Church gatherings at Coast Community Church and on social media. (no names or other details will be used)

Permission to attend Kids/Youth Events *

Yes

Tip: by ticking this box you are giving permission for your child to attend Kids/Youth programs or events at Coast Community Church

Name *

Tip: Your name (must be completed by a parent or legal guardian)

Todays Date *