First Baptist Mena After School Registration

Parent/Guardian Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Cell Phone:
• Phone:
• Home Church
• Please list the names and phone numbers of the persons who are authorized to pick your child up besides you.
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Participant Information (Please click add child below)

You may add a maximum of 10

Permission/Release:

• *

  Medical Release: I authorize First Baptist Church Mena, and the volunteers thereof, to seek medical care for my child/children in the event of an emergency when I or a guardian cannot be reached. I assume liability and agree to pay all costs and expenses in connection with any medical services rendered to my child/children.

  • Yes
  • No
• *

  Transportation Release I hereby give permission for my child/children to ride the church van. This includes all activities and outings that are sponsored by First Baptist Church Mena. I accept full responsibility for my child/children and will not hold First Baptist Church Mena responsible for any accident leading to injury to my child/children.

  • Yes
  • No
• *

  Walking Home Release: I hereby give express permission for my child to be allowed to walk home at the close of activities from the church to their home. I understand that children under the age of twelve (12) must be accompanied by an older sibling for this to apply to them. I release First Baptist Church Mena from any liability or injury to my child/children that may occur as they walk home.

  • Yes
  • No
• *

  Publicity Release: I consent to the photographing, videotaping and/or audio recording of my child/children to be used by First Baptist Church Mena in the promotion of the ministries of the church.

  • Yes
  • No
• *

  My child needs to ride the church van/bus home.

  • Yes
  • No
• Other Comment or Special Need:
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Parent or Legal Guardian Signature

• * I hereby give permission for my child/children to participate in children/youth programs at First Baptist Church Mena. Sign and Date please