Kidz Central Information Sheet
Child's Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent Home Phone number
Your answer
Parent Cell Phone number *
Your answer
Parent Work Number
Your answer
Student Age *
Your answer
Student Gender *
Student Date of Birth *
MM
/
DD
/
YYYY
Current School
Your answer
Grade Completed *
Allergies
Your answer
Interests
Your answer
Parent's Name *
Your answer
Other Emergency Contacts (Name and Phone Number)
Your answer
Child's Doctor
Your answer
Hospital Preference
Email
Your answer
For VBS, who would your child prefer to be grouped with?
Your answer
Where did you hear about us?
Others who have permission to pick up my child.
Your answer
By submitting this form, I give permission for the Staff at Christ Central Church in Rainbow City, AL, to provide care and perform basic first aid care for my child. If my child requires emergency care, I give permission for my child to be treated by emergency personnel until I can be reached. *
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