This completed form is necessary for participation in our program.

Kingdom Kids - Konnect 56

Child’s name____________________________________ Grade_____ Age_____ Birth Date _____________

Address ______________________________________________________ Home Phone _______________

City ___________________________________________________________________________________

Parent/Guardian name____________________________________________ Cell Phone ________________

Address______________________________________________________ e-mail _____________________                                                                                                                                                     (if not the same)

MEDICAL INFORMATION/CONSENT FORM

Emergency contact, in case parent cannot be reached: Name_____________________ Phone _____________

Circle any medical condition the student has: Diabetes Epilepsy Asthma Heart condition Kidney condition

Allergies: _______________________________________________________________________________

Special needs: ___________________________________________________________________________

Are all immunizations current? __Yes __No Date of last Tetanus Shot_____________________

CHILDREN MAY NOT BRING TOYS OF ANY KIND, REAL OR TOY WEAPONS OF ANY KIND, INCLUDING

POCKET KNIVES TO KINGDOM KIDS. ITEMS WILL BE TAKEN FROM CHILD AND RETURNED TO PARENTS.

I hereby give permission for the above named child to participate in “Kingdom Kids”, a ministry of First Baptist

Church of DeKalb, Texas. I further give my permission to the leaders of First Baptist Church to render necessary

First Aid, administer non-corporal forms of discipline and provide transportation to and from specific sites that I

have had previous knowledge of prior to the child being transported. I realize that the activities of the program

will be BIBLE CENTERED AND CHRISTIAN ORIENTED. I further understand that while in the care of the

leadership of First Baptist Church, the child will be given the utmost care and respect, but from time to time kids

need to be reminded that acting in an appropriate manner is expected. We have adopted a Three Strike rule that

will help remind those who need to be reminded. After the third strike, the child may NOT attend Kingdom Kids

for a determined period of time. Parents will receive notice upon the third strike.

Parent Signature___________________________________________ Date __________________________

NOTE: We do not normally provide transportation to and from Kingdom Kids. If special needs are present, please call                                                                                                                                           the church office for additional information.