Child's Name       Gender Boy Girl      Age 3 4 5 6 7 8 9 10 11 12 13 14      Grade Completed None Yet Pre-K Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth

Name of person filling this form: Relationship Father Mother Grandparent Legal Guardian Other  
If "Other" explain     

Phones: Home 727 813 -  Work()-  ext    
Cell ()-  

Email

Address - Please list full physical address and mailing address if different:

Medical Issue - Please use the space below to indicate any medical issues such as allergies, disabilities, medications, prostheses, or anything else we should know in case of an emergency. Do not blank, if there are no issues, ender "None"

Emergency Contact(s)  If there are no answers at the phone numbers entered above whom should we contact?

Contact # 1 Phone ()-   Contact # 2 Phone ()-

Dismissal Information: Please list the names and relationship of each person authorized to pick up your child after VBS each day

Does the child attend Sunday School? If yes, where

If child is visiting a Countryside member, who is that member?

Read Agree By selecting "Agree", I indicate that I have read and understand Countryside Baptist's photography policy, to wit: Photographs may be taken of you or your children in public areas without prior consent and may be used for promotional purposes. Upon request, we will remove a photograph from our website for any or no reason.  We will remove it quickly, cheerfully, with no questions asked.

Please review your answers CAREFULLY, then click Submit