Kids Ministry & Nursery Registration 2023-2024 | First Baptist Church of Delphi

Please complete one form no later than August 1, 2023 for each child in your family nursery through 6th grade. NOTE: The following information is very important for the care of your child. As such, this information will be available to all approved childcare workers. If you would like to keep any of this information confidential, please contact the Kids Ministry Coordinator.

By submitting this form you hereby confirm that all information is true and accurate to the best of your knowledge.

Child's First and Last Name (Required)

Child Information

Child's Birthdate (Required)

Child's Age as of September 1, 2023 (Required)

Child's Grade as of Fall 2023 (Required)

Father/Male Guardian Information

Father/Male Guardian

Father/Male Guardian Address

Father/Male Guardian Phone

Father/Male Guardian Email

This address will receive a confirmation email

Mother/Female Guardian Information

Mother/Female Guardian Name

Mother/Female Guardian Address (if different from above)

Mother/Female Guardian Phone

Mother/Female Guardian Email

This address will receive a confirmation email

Medical History

NOTE: Neither First Baptist Church nor its caregivers will administer prescription or over-the-counter medications of any kind, in any circumstances, with the exception of epinephrine injectors. If an epinephrine injector is necessary for your child, please contact the Nursery Director or Kids Ministry Director. It will be the parents’ responsibility to properly train the caregivers in the proper administration of an epinephrine injector.

Please provide any significant medical history, psychological history, or other pertinent information that will be useful or necessary in caring for your child or in an emergency. Please be as complete as possible. (Required)

Please list any medically significant allergies to medication or food: (Required)

Dietary restrictions. Please state whether for medical or other reasons: (Required)

Please list any current medications your child is taking: (Required)

Does your child carry an Epi-pen? (Required)

Yes

Is your child up-to-date on their Tetanus booster? (Required)

Yes

I don't know

Date of last Tetanus booster (if applicable)

Physician's Name (Required)

Physician's Phone (Required)

Emergency Notification

If I am unavailable in the case of emergency please notify:

Emergency Contact's Name (Required)

Emergency Contact's Phone (Required)

Emergency Contact's Alternate Phone

Pick Up and Drop Off with Nursery Ministry

Only parents will be allowed to drop their children off and pick them up from the Nursery Ministry. However, should the parents wish for someone else to drop off or pick up their child(ren), the parents of children ages 0-Kindergarten must obtain the consent of the Nursery Coordinator and/or Sunday School Superintendent and return either a completed Children’s Ministry Child Release Form (if they desire an older sibling to drop-off/pick-up a younger sibling, or give self-check-in privileges to children 3rd grade and above) or a completed Permission for Alternate Drop Off/Pick Up Form prior to the parent’s absence, should the parents desire someone other than themselves to bring their child to church. These forms are available at the Nursery counter or Children’s Ministry Desk.

Permission

I do hereby give permission for my above-named child to participate in ALL programs and events sponsored by First Baptist Church, of Delphi, Indiana, whether at church or off-site and transportation to and from any programs and events. I understand that, in the case of an emergency First Baptist Church, employees, agents, members and/or sponsors will make every effort to contact me and/or the named contact person; however, should the named contact person, or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for First Baptist Church employees, agents, members, and/or sponsors to obtain emergency medical attention in case of sickness or injury, to my child, up to and including hospitalization, and for an attending physician or hospital to perform whatever care is deemed necessary for the welfare of my child, and I understand that I am responsible for any expenses incurred.

Hold Harmless

I hereby release, absolve, indemnify, hold harmless, and forever discharge First Baptist Church, its employees, agents, organizers, sponsors, members, or any supervisors appointed by them from any and all claims, demands, actions or cause of actions, past, present, or future arising out of injury or damage to my child while participating in any program or event, or from any check-in/check-out policy. I assume all risks and hazards incidental to the conduct of the programs or events and check-in/check-out policy. In case of injury to my child, I hereby waive all claims against First Baptist Church, its employees, agents, organizers, sponsors, members, or any supervisors appointed by them. ***If you choose to later revoke this permission/release it must be done in writing. ***

Parent/Guardian Electronic Signature

By entering your full name in this field you agree to the above terms. You are also agreeing that this electronic signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility. You may opt out of an electronic signature by requesting a paper copy of this document from the sending party, which you can then sign and return in person.

Parent/Guardian Electronic Signature (Required)

Date of Signature (Required)

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First Baptist Church of Delphi

103 S INDIANA ST
DELPHI IN 46923-1328

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