Information and Authorization Form
Information and Authorization Form
Please complete the following form with information that is thorough and accurate. Your completion of this form will help us to care for your child. Thank you!
GENERAL INFORMATION
Child Name*
Date of Birth*
Child's Cell Phone No.*
Child's Email Address*
Home Address*
City*
Parent/Guardian Name(s)*
Preferred Phone No.*
Secondary Phone No.*
Preferred Email Address*
Secondary Email Address*
Emergency Contact (if neither parent is available)*
Relationship*
Phone No.*
MEDICAL INFORMATION
Physician*
Physician's Phone No.*
Is your child up to date with their vaccinations?*

Please list any allergies your child has (animals, insects, foods, medications, etc.)*
Are your child's activities restricted in any way that we, as church staff and volunteers, should be made aware of? Please explain.*
Are there any special needs of other information that will help us to better serve your child? Please explain.*
INSURANCE INFORMATION
Insurance Company*
Primary Insured*
Primary's Date of Birth*
Policy No.*
Group No.*
PHOTO GUIDELINES
Creekwood Christian Church uses photos in brochures, slide shows and videos. Photos are also used for marketing purposes, including website. Names will not be associated with individual children. It is Creekwood’s intent to use these photographs as a means to build the self esteem of young people and to inform and attract any individual who wants to encounter the spirit of Creekwood as it relates to Christ’s ministry and love. Please be advised that photos of your child/youth (without names attached) may be used in the following ways, including but not limited to: a) In-house publicity (i.e. slide show/video, brochure, newsletter) and b) External publicity (including website, social media and newspaper).
Do you give Creekwood Christian Church consent to use photos of your children for the purposes listed above?*

TRANSPORTATION RELEASE
Do you give permission for your child to ride with an approved driver to and from Creekwood sponsored events? If so, please write your initials.*
Do you give full consent for your child to participate in Creekwood approved activities both on and off the church campus? If so, please write your initials.*
Do you hereby release CCC and its ministers, employees, volunteer leaders, and other representatives from any liability or other legal or financial responsibility for supervision of the above-named child. In the event of any such accident or other situation in which the above-named child may require emergency medical or dental care, do you hereby authorize an adult representative of CCC, in your absence, to seek out and consent to any necessary medical or dental care for the above-named child, when either you or your emergency contact cannot be reached? Do you understand that every effort will be made to contact you before such action? If so, please write your initials.*
THE LAST AND MOST IMPORTANT THING
Please share with us three things that you hope your child receives from their experiences with Creekwood Christian Church Children and Youth Ministries*