Child's Name:

Address: 

Phone:

Age/Grade:

Parent/Guardian Name:

Allergies: 

Pediatrician's Name:  Pediatrician's Phone: 

Emergency Contact:
Emergency Contact's Phone:

Disclaimer: By completing this online registration, I hereby release Lakeside Family Church, staff members and volunteers from all liabilities relating to any medical situation. In addition, I give staff members and volunteers permission to administer first aid, or make medically necessary decisions in case of illness or injury. understand that a staff member or volunteer will contact me immediately in such situation.