Central Kids Registration and Emergency Contact Information
Central Baptist Church
201 West 4th Street
(606) 528-6650
Contact our Children & Families' Pastor, Josh Pollitt at jpollitt@gocentral.org
Email address *
Emergency Contact Information
Emergency contacts MUST be an adult over 21 or legal guardian. You MUST provide two emergency contacts. Furthermore, you are to be the legal parent/guardian of the children you are completing the form for.
Primary Address of Family *
Your answer
City *
Your answer
State *
Your answer
Where do you attend Church on Sunday? *
Your answer
Are you a member of that church? *
How often does your family attend church?
1st person to contact in case of emergency
First Name *
Your answer
Last Name *
Your answer
Emergency Contact Number *
Your answer
Emergency Contact Relationship to Child *
Primary emergency contact MUST be a legal guardian.
Secondary Emergency Contact Name *
First and Last Name
Your answer
Secondary Emergency Contact Number *
Your answer
Secondary Emergency Contact Relationship to Child *
Next
Never submit passwords through Google Forms.
This form was created inside of Central Baptist Corbin. Report Abuse - Terms of Service