Wednesday Night Kids
Please fill out this form and click submit.
Child Name
*
Address
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Birthdate
*
Grade
*
Please select one option.
K
1st
2nd
3rd
4th
5th
6th
Select Option
K
1st
2nd
3rd
4th
5th
6th
Please list any known allergies/medical information BG kids should know?
Parent Information
Parent/Gaurdian Name
*
Parent/Guardian Cell Phone
*
Media Waiver
- I hereby grant permission to Beech Grove Baptist Church to use my image/voice in any official church publications---printed or web-based---without further consideration. - I acknowledge the church's right to crop, edit, or otherwise treat any photo's recordings at its discretion. -I also acknowledge that the church may chose not to use my image or voice at this time but may do so at its own discretion at a later date. -I understand that once my image/voice is posted on Beech Grove Baptist Church's website or any of its social media profiles that it may then be downloaded by any computer user, anywhere in the world. -The church reserves the right to discontinue the use of any images/recordings at any time, without notice.
*
Please select one option.
Therefore, I agree to indemnify and hold blameless the church, its pastor, staff, members, and designees from any claims arising from the use of my image or voice.
I do not grant my permission for the church, its pastor, staff, members, and designees to the use of my child's image or voice
Select Option
Therefore, I agree to indemnify and hold blameless the church, its pastor, staff, members, and designees from any claims arising from the use of my image or voice.
I do not grant my permission for the church, its pastor, staff, members, and designees to the use of my child's image or voice
Emergency Contact
Please list one contact other than yourself
Name
Phone number
Relationship to Child
Submit
Description
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