Parent/Guardian's Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name *

First Name

Last Name

Child's Birthday *

MM

DD

YYYY

I hereby release Lone Star Church, the Nursery Department, and Volunteer Staff from all liability, claims, demands, causes of action, and possible causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained while my child is attending the nursery class. *

I Agree

I Do Not Agree

Does your child have Allergies? *

Yes

No

I agree that, for the safety of my child and others, if my child is sick, has had a fever in the past 24 hours, or is showing any other signs of sickness, I WILL NOT bring them to the Nursery Class that day. *

I agree

I Do Not Agree

Lone Star Church has my permission to photograph my child. I understand that these images may be used on the church website and various social media. I also understand that I will not receive any form of compensation for these photos. *

I give my permission

I DO NOT give my permission

Would you be interested in volunteering in the nursery? *

Yes

No