Parent/Guardian Full Name(s) * First Name Last Name Phone * Parent or Guardian (###) ### #### Email Parent or Guardian Childs Full Name First Name Last Name Age (of Child) Date of Birth (of Child) Grade in School Gender (of Child) Does your child have any special needs including medical, behavioural or emotonal needs? * Yes No Does your child have any allergies? * If yes, please specify. Yes No Any food requirements for your child? If so, please specify. Do you give permission for your child(ren)’s image, voice, and likeness to be recorded and used for promotional purposes, including on Potters House Fairfield Church’s website and other media platforms? * Church Website, Promotional Videos and Pictures Yes I give permission. No I do not give permission. Other Information? Is there anything else you would like to share with us about your child or your family? Thank you!
