Children's Registration & Permission Form

Heart of Longmont's Children & Family Ministry (CFM) offers programming for children in Kindergarten through 5th Grade, and provides nursery care for children from birth to pre-K. Please complete this form for your child. The information will only be used for the purposes of CFM programs and will not be shared outside of the Heart of Longmont.

Please note: We need one form per child.

Child's Name

Age of Child

Date of Birth

Child's School Grade

Child's School Name

Does your child have any allergies?

Yes No

If child has allergies, please list.

Does your child have any special needs?

Yes No

If child has special needs, please list.

Please share any additional considerations we should be aware of about your child.

Does your child have any siblings?

Yes No

If child has siblings, please list name(s) & age(s).

Child's Home Address

Caregiver1 Full Name

Caregiver1 Cell Number

Caregiver1 Email Address

This address will receive a confirmation email

Caregiver2 Full Name

Caregiver2 Cell Number

Caregiver2 Email Address

Emergency Contact: Name, Relationship, and Phone Number. *please note: we will always try to reach the caregivers listed above first. This contact will only be used if we cannot reach them.

I give my child permission to participate any church related activity. I further give my permission to the Heart of Longmont staff and any other adult recognized as a childcare provider, chaperone, or organizer to obtain and administer such medical aid as might be required for the immediate care of my child in the event of an emergency. I also give my permission to include the administration of such medicines or treatment as might be ordered and/or administered by a duly licensed physician or medical professional. I understand and agree that I will be liable for any expenses incurred that are not covered by my health insurance or if no insurance is available.

Yes No

Do you give consent for your child's photo/video to be used in church communications, including print and digital outlets? (note - names are not published with photos).

Yes No

Would you be willing to volunteer as needed in HOL Children & Family Ministries?

Yes Not at this time

If there is any additional information you would like us to know about your child, please use the space below.

Behavioral and Safety Guidelines

As we try to provide a safe and fun environment that is conducive to learning and growth, we ask that all caregivers and children follow our behavioral and safety guidelines when they participate in any Children & Family Ministry programs at Heart of Longmont. View these guidelines at heartoflongmont.org/children-and-family-ministries.

I have read and understand the guidelines and will support my child in adhering to them.

Yes No

Children's Registration & Permission Form

Description

Please Fix the Following