CHILD INFORMATION SHEET

CHILD INFORMATION SHEET

Black Oak Heights Baptist Church

Mother’s Day Out

Last Name:_______________________First Name:_____________________MI:______

Address_________________________________________________________________

City_______________________State:__________________________Zip:___________

Name

Place of Employment

Home Phone

Cell Phone

Mother

Father

Child’s Birthday: ________________________________________________________

Siblings (& ages): ________________________________________________________

______________________________________________________________________

Allergies /Medical Concerns: _______________________________________________

_____________________________________________________________________

Yes No

Are you a member of a Church? ____ or ____

If so, what church? _____________________________________________________

For the child’s safety, please list persons to whom the child may be released:

Name/Relationship	Home Phone	Work Phone	Cell Phone

PERMISSION SLIP

Black Oak Heights Baptist Church

Mother’s Day Out

I/We__________________________________,do hereby give my/our permission for ____________________________________, my/our child to be treated in an emergency situation by Children’s Hospital and/or Knox County Ambulance Service. I/We understand that in case of an emergency, I/We will be contacted as soon as possible.

__________________________________________

Parent or Guardian Date

__________________________________________

Parent or Guardian Date

INSURANCE INFORMATION

Name of insurance company___________________________________________

Policy Number ________________________

Group Number_____________