Children’s Ministry Guest Registration 2019-2020 Children’s Ministry Registration – Guest Parent Contact Information Parent Name (first and last) * Parent Address * Parent Address Parent Address Parent Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Parent Email * Parent Phone * Emergency Contact Name & Phone * For Each Child Child Name (first & last) * Child Birthdate * Child Grade for 2019-2020 School Year * 3'sPre-KKindergarten1st2nd3rd4th5th6th Alergies Peanuts Eggs Tree Nuts Bee stings Milk Red Dye #7 Wheat (gluten) Latex OtherOther Reaction to allergens * May an adult at Saint Luke’s administer general 1st aid including Tylenol, Benedryl, and antibiotic ointment? * Yes No List any conditions with which your child has been diagnosed. List any medical devices your child carries (e.g, inhaler, epi-pen) List any other food or activity restrictions What else should Saint Luke’s know in order to make your child’s time here more enjoyable? plus1 Add other child minus1 Remove this child Other Information Who may pick up your child(ren)? * Who may NOT pick up your child(ren)? May an adult at Saint Luke’s call 911 for your child(ren) in case of an emergency? * Yes No Does Saint Luke’s have your permission to use any images or videos in which your child appears for promotional media? YesNo Submit