This form is required if children are to be left in the care of the church during Sunday morning worship and other services.

    Please fill out this form to allow us to teach & care for your children in our Preschool Dept. while you go to our Adult Worship Services.
    This consent shall remain in effect until...(write in date or "indefinitely")

    Your name

    PARENT/LEGAL GUARDIAN(S)

    Father/Guardian 1

    Mother/Guardian 2

    Address


    Email Address

    CONTACT NUMBERS

    Father/Guardian 1
    Home Phone
    Cell Phone

    Mother/Guardian 2

    Home Phone
    Cell Phone

    Other
    Home Phone
    Cell Phone

    ADULTS (18 OR OLDER) AUTHORIZED TO PICK UP MY(OUR) CHILD(REN)
    Will be required to to show photo ID at time of pick up.

    Adult 1

    Adult 2

    Adult 3

    Adult 4

    MEDICAL/BEHAVIORAL INFORMATION
    List for each child

    Child One

    DOB

    Allergies (drugs/food)

    Chronic Illnesses/Conditions

    Regular Medications

    Other Instructions or Comments

    Child 2

    DOB

    Allergies (drugs/food)

    Chronic Illnesses/Conditions

    Regular Medications

    Other Instructions or Comments

    Child 3

    DOB

    Allergies (drugs/food)

    Chronic Illnesses/Conditions

    Regular Medications

    Other Instructions or Comments

    OTHER AUTHORIZATIONS
    My child(ren) has(have) permission to participate in the ministries of Riverview Baptist Church.

    DOB

    My child(ren) has(have) permission to have their photographs in publications of Riverview Baptist Church.

    DOB