Terrific Tuesdays Registration
 For Children First - Sixth Grades the past school year.

Applicant Name                         Date

E-mail                 Phone   

Child's Name

Address City State Zip

Child's Age      School Attended      Grade

Church Membership YesNo       If Yes, Where

Emergency Contact             Phone

Please list any food, medications, etc. that your  child is allergic to in space below:


I give permission for photographs, audio, and video to be taken of my child while engaged in activities and for these images to be used in media, on web sites, and in any other promotional materials related to Moulton Baptist Church.
YesNo

I give permission for my child to participate in the Terrific Tuesday's program of Moulton Baptist Church. Rules will be in play and participants will be supervised. However, I acknowledge that there is the possibility of accidents. I release the coordinator, adult and youth volunteers from all claims, in the event of an accident to my child, unless the injury is the results of gross negligence or willful misconduct on the part of these parties.
Yes

   Parent / Guardian
I agree with the information above.    Yes No

Would you as a parent/adult like to be involved this summer? Yes No