Orchard Crest Baptist Church Children/Youth Department Emergency Form

(one form per family)


Child 1: Full Name:   Birthday:

School Grade:   Gender (Male/Female): 

Church Member (yes/no):   Saved (date):   Baptized (date): 

Allergies/Health Problems: 


Child 2: Full Name:    Birthday:

School Grade:  Gender (Male/Female): 

Church Member (yes/no):  Saved (date):  Baptized (date):

Allergies/Health Problems:


Child 3: Full Name:    Birthday:

School Grade:  Gender (Male/Female):

Church Member (yes/no):  Saved (date):  Baptized (date):

Allergies/Health Problems:

(If more than 3 children, fill out a second form)


Parent/Gaurdian Name: 

Parent/Guardian Address: 

Parent/Guardian Email:   Parent/Guardian Phone Number: 

 I authorize medical treatment for my child in case of accident/illness if parent/guardian can't be reached/located or an emergency situation should arise.
Hospital Choice: 
 I authorize my child/youth photo to be used on social media, church advertising, webpage etc.
Church Van Pickup (yes/no):      Sunday    Wednesday 

Other emergency contact/authorized pickup:
1:   Name:     Phone Number: 
     Address: 
2:  Name:      Phone Number: 
     Address: 
3:  Name:      Phone Number: 
     Address: 

Parent/Guardian Signature:      Date: