Tending the Vine Registration
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Child's Name *
Birthdate *
Current Grade Level & Teacher *
Age *
Sex *
Street Address *
City *
State *
Zip *
Parent/Guardian *
Parent/Guardian email  *
Phone Number *
Alternate Phone Number *
Secondary Contact In Event of Emergency *
Secondary Contact Phone Number *
Secondary Contact Relationship to the child *
Medical Insurance Company, Group # and Policy # *
Physician's Name *
Physician's Phone Number *
Please Indicate any medical conditions of which we need to be aware; including allergies, rare blood type, asthma, seizures, wears glasses/contact lenses, etc.: *
Name of persons authorized to pick up child: *
In the event of a medical emergency where I can't be reached, I agree to give the leaders of First Baptist Church of Litchfield permission to consult an available physician, and the physician permission to treat my child as needed.  I further agree to permit my child to be transported to a medical facility by ambulance or other commercial vehicle.  This authority is granted only after a reasonable effort has been made to reach me by phone at the numbers I have provided. As the parent/guardian of the child listed above, I promise to hold First Baptist Church of its volunteers blameless for any liabilities that may incur in connection with the event. *
I give permission for my  child to be transported by the First Baptist Church Vehicles *
May FBCL take/use photographs and videos of your child and post on our website or Facebook account *
First Baptist Church would like to have copies of your child's Progress Reports/Grade when received from the school. *
TTV Handbook   I have read attached handbook and consent to the policies outlined in the Tending the Vine Handbook *
*
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