Child Information/Permission Form 2019
This form must be turned in at the time of registration for AIM
This form must be completely filled out individually for each child. Parents must sign.
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Child Name:                          Date of Birth:                        Age: *
Address: *
Phone Number (Home):         Cell Phone: *
Work Number (Parent or Guardian) *
Chaperone/Youth Leader Name *
Chaperone/Youth Leader Phone Number (Home or Cell): *
Chaperone/Youth Leader email address: *
In case of emergency notify:   *
Chuch:                 Pastor:        
Medical Information
Please Check all that apply to your child.
Please list all medications child is currenlty receiving:
Has child ever been hospitalized or had any allergies? If so, please explain.
Child's physician:   Phone#:
Medical Insurance Company:     Policy#:
Parent/Gurdian Electronic Signature:
Parents please included your birthdate.
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