Child's Name *

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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May we have permission to use your child's photograph on social media and for the purpose of promotion? *

Yes

No

My child has my permission to attend the Progressive Dinner on December 16, 2018. I realize that there is risk associated with any activity and I assume full responsibility for the welfare of my child. I will not hold First Baptist Church, nor any of its sponsors, leaders, staff, agents or representatives responsible in cases of injury or illness. This statement authorizes the church sponsors to seek medical and/or surgical treatment in the event of an emergency. *

I agree