BloomCo kids registration • Bloom Co

Parent/Guardian Information

First Name

Last Name

Phone Number

Email Address

Relationship to child

Child Information

Name

Date of birth

Age

Special needs or notes

We want to make sure your child feels comfortable and supported! Please provide any important details (such as behavioural needs, anxieties or extra supports etc).

special needs

Emergency contact (if parent unavailable)

Name

Number

Relationship to child

Medical and Dietary requirements

Any allergies, medical conditions, diagnoses (e.g. autism, ADHD, asthma, diabetes, epilepsy, etc.), or medications we should know about?

Condition

Allergies/Dietary restrictions

Pickup authorisation

We want to make sure your child goes home safely! Other than you who else can pick up your child

Name

Custody Information

Are there any custody agreements, court orders, or special arrangements we should be aware of? (For example: limited visitation, pickup restrictions, etc.)

If Yes please let us know what we need to be aware of

Consent and Agreement

I give permission for my child to participate in all scheduled Kids Church activities.

Yes

I'm happy for photos or videos of my child to be taken and used for church updates and activities.

Yes

I give permission for the BloomCo Kids Church team to seek emergency medical care for my child if needed.

Yes

I confirm that only the people listed above (or myself) will pick up my child.

Yes

I agree to the program's behaviour guidelines that my child will abide by (found on BloomCo website).

yes

Signed by

Date