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Parent First & Last Name

Phone

Address:

Emergency Contract Information: Name & Phone Number

Child 1 - Name

Child 1 - Birth Date

Child 2 - Name

Child 2 - Birth Date

Child 3 - Name

Child 3 - Birth Date

Allergies/Medical Conditions/Medications:

I hereby ________ permission for Faith Fellowship to use my child on its website for informational or promotional purposes.

Website Permission

Grant

Do Not Grant

Child Pick-up Authorization

Main pick-up person(s)

Additional person who may pickup child

Any person(s) NOT authorized to pickup child

Sunday Service: 10 - 11am

Sunday School: 9 - 9:45am

1694 Highway 152 Osceola, Iowa

(641) 414-3935