Child's Name *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Last school grade completed *

Nursery

Pre-K

Kindergarten

1st

2nd

3rd

4th

5th

6th grade or higher

Parent's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Do you give consent for First Baptist Church to use pictures of child on the church website/Facebook for informational or promotional purposes? *

Grant consent

DO NOT grant consent

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

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