Seattle Bethany Church

Child First Name

Child Last Name

Child Date of Birth MM/DD/YYYY

First Name

Last Name

Email

Phone Number

Do you want to add something about your child?

I, undersigned, agree with the following statements:

I am the parent/guardian of the child indicated above.
Yes

If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.
Yes

I am giving my permission to take my child's pictures for classroom projects and post them on the church website.
Yes

Name of person completing form: