Children’s Registration Form

Looking to register your child for Sunday morning programs or your 1st-6th grader for Wednesday nights? Please complete the form below. You are welcome to just show up, however these registration forms will help us be better prepared to warmly welcome your child! For our Wednesday evening program, we also need a release form signed. This form may be found HERE.

Children's Ministry Registration Form

Registration for all children's school year programming 2014-15.

Child's Name*
First Last
Date of Birth (mm/dd/yyyy)*
Current Grade Level*
Please list anything of importance for the classroom leader to know. (i.e. allergies, heart condition, history of respiratory illness or asthma, hemophilia, present injuries/limitations, handicaps, disabilities, other concerns of importance right now.)
Parent/Guardian 1: Name*
First Last
Parent/Guardian 1: Address*
Street Address City ZIP Code
Parent/Guardian 1, phone*
Parent/Guardian 2: Name
First Last
Parent/Guardian 2: Address (if different from above)
Street Address City ZIP Code
Parent/Guardain 2, phone
Additional phone number(s)
Please select your choice of hospital,in the event you cannot be reached.*
Emergency Contact Name*
Please list someone other than the parents or guardians, in the event you cannot be reached.
First Last
Emergency Contact Phone Number*
If you would like your doctor or dentist's name and phone number on file in case of an emergency and you cannot be reached, please list them below.
I agree to allow photographs of my child to appear in promotional or media materials for the Countryside Kids program. (Please note: children's names will not be listed.)*
- Yes
- No
- Yes, with the exceptions noted in the field below
Please list exceptions below.
The following people are authorized to drop off and pick up my children. (Please list first and last name, along with phone number if it is not already listed on this form.)*
Announcements and information regarding the Children's Ministry will be sent by email, usually on Tuesday afternoons. Please provide at least one email address so you can receive this information. If you do not have regular internet access, please note that below.*
Second email address (if applicable):
Sunday Small Groups: I authorize my 5th-6th grade student to be released at the end of Sunday School to meet me at a designated location within the church. I understand that once my children leave the Sunday School classroom, I assume full responsibility for them.
Please note: This is for Sunday mornings only. Wednesday night programming must be picked up from their last location. If this field remains unmarked, students must be picked up by a parent/guardian.
- Yes
- No, we will pick our child up from the classroom
By checking the box below, my student and our family have reviewed and agree to follow the Children's Ministry Guidelines and agree to the Program Liability Release form that is found at www.countrysideumc.org/children/childrens-release-form/*
- We have read and agree to the policies and liability release.

Children's Ministry Registration Form

Share this: