Kidz Central Information Sheet
Child's Name *
Address *
City *
State *
Zip Code *
Parent Home Phone number
Parent Cell Phone number *
Parent Work Number
Student Age *
Student Gender *
Student Date of Birth *
Current School
Grade Completed *
Parent's Name *
Other Emergency Contacts (Name and Phone Number)
Child's Doctor
Hospital Preference
For VBS, who would your child prefer to be grouped with?
Where did you hear about us?
Others who have permission to pick up my child.
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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