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.
Sign in to Google to save your progress. Learn more
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.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy