Kids Church Registration Form • Yountville Community Church

Welcome and thank you for registering your child(ren) to Yountville Kids! We are looking forward to working in partnership with you, as together we encourage, disciple and pray for your children to grow in their relationship with Jesus as their Lord and Savior.

We encourage you to read our Overview of Kids Church Policies for Parents/Guardians before registering your child.

For more information about Yountville Kids, go to our website yountvillechurch.org/kids

Parent/Guardian 1

Full Name *

Mobile Number *

Email Address *

Relationship to Child *

Does this Parent/Guardian live at the primary residence of the child(ren)? *

List full names (and their relationship to the child) of other adults authorized to pick up your child:

Parent/Guardian 2

Full Name

Mobile Number

Email Address

Relationship to Child

Does this Parent/Guardian live at the primary residence of the child(ren)?

List full names (and their relationship to the child) of other adults authorized to pick up your child:

Primary Residence of Child(ren)

Home Address *

Address Line 2

City *

State *

Zip Code *

Emergency Contact (other than Parent/Guardian)

Full Name *

Relation to child(ren) *

Mobile Number *

Child's Information

Please complete seprately for each child.

Child 1

First Name *

Last Name *

Date of Birth *

Gender *

School Grade *

Allergies or Special Needs? *

Please list any allergies or special needs below:

Child 2

First Name

Last Name

Date of Birth

Gender

School Grade

Allergies or Special Needs?

Please list any allergies or special needs below:

Child 3

First Name

Last Name

Date of Birth

Gender

School Grade

Allergies or Special Needs?

Please list any allergies or special needs below:

Child 4

First Name

Last Name

Date of Birth

Gender

School Grade

Allergies or Special Needs?

Please list any allergies or special needs below:

Acknowledgements

I understand and agree that for my child to participate in the Kids Church program on Sundays that at least one of the child's parent/guardian will remain on the church grounds for the duration of the program. *

I agree that by giving my email address, I understand that I will be added to Yountville Community Church and Kids Church email distribution list. Yountville Community Church will not give my personal information to any third party. *

I give my consent and agreement that my child's image may be photographed, filmed or used in video, print or, online material to promote Yountville Community Church's Kids Church program. No names will be used on the website or in press releases. *

I agree that if the parent/guardian and/or the emergency contact cannot be reached, the staff members and volunteers of Yountville Community Church Kids Church have my permission to take whatever actions deemed necessary to ensure the safety of both my child(ren) and any other children involved. *

Thank you for registering your child(ren) for Kids Church at Yountville Community Church. We are looking forward to partnering with you as we share the hope we have in Jesus with the Napa Valley and beyond!

If you have any questions, please contact our office at 707-944-2179 or email us at info@yountvillechurch.org

Signature

Printed Full Name of Parent/Guardian *

Digital Signature *

Date *