KPT - Personal Information

Child's Information

Name

Birthdate

Gender

Male Female

Child's siblings (Names & Ages)

Parent Information

Mother's Name

Address

This address will receive a confirmation email

Mobile Phone

Spouse Name

Spouse Cell Phone

Occupations - Mother & Spouse

Would you like more information about Peace Church?

Yes No

Do you give permission for pictures to be taken of your child to be used for crafts at KPT?

Permission Granted to Take Photos

Yes No

In addition to the parents listed on this form, the adults authorized below may pick up this child. This child will only be released to an authorized adult on a day by day basis with your permission. This child's pick up sticker and a valid driver's license or photo ID must be presented to this child's teacher before this child will be released.

Authorized Adults for Pickup

Child's Medical Information

List ONLY Food or Drug ALLERGIES in the space below. If NONE, please LEAVE BLANK.

Allergy Type

If your child carries an epi pen, please list the expiration date below. (Leave BLANK if not applicable.)

Date

Is your child up to date on their immunizations?

Yes No

If no, please explain.

Liability Release

By checking the box, I hereby release, discharge and agree to hold harmless Peace Church and its employees, volunteers and agents from any and all liability, claims or demands for personal injury, sickness, or other harmful occurrences resulting from my child's participation in this program. Furthermore, I agree to assume all responsibility for any of the previously mentioned occurrences. I give my permission for the personnel of Peace Church to secure emergency medical treatment as deemed appropriate at the medical facility they select. I agree to assume financial responsibility for this treatment. I understand that there is no special liability coverage in this program.

Agree

Child's Personal Information

Is your child potty trained?

Yes No

How would you describe your child's personality?

Does you child have a comfort item? (blanket, pacifier, etc.)

What other programs has your child experienced? (Sunday school, ECFE, daycare, etc.)

What are your child's favorite activities, toys, pets, etc.?

What do you hope your child will gain by attending KPT?

Please share with us anything else about your child that you think would be helpful.

KPT - Personal Information

Description

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