Child Medical and Photo Release Form

Parent or Guardian of children attending any of the 2022 Wyld Wednesday events must fill out the form below. Thank you!

Medical and Photo Release Form

Parent/Guardian Name(Required)

First Last

Email(Required)

Main Phone(Required)

Alt Phone

Child 1: First and Last Name(Required)

Child 2: First and Last Name

Child 3: First and Last Name

If registered more than three children please use the "Other Comments" field below.

Does your child have any allergies or medical conditions?(Required)

Yes

Medical and Allergy Information

Please add the name(s) of the child and the medical condition or allergy that should Sea Road volunteers should be aware of.

Emergency Contact(Required)

Please provide an emergency contact in addition to the main parent/guardian above.

First Last

Emergency Contact Phone(Required)

Media Release(Required)

I hereby grant permission for the image of the child(ren) listed on this form to be included in pictures, promotional material, and publications connected with Wyld Wednesday at Sea Road Christian Church. I understand that the child(ren)(s) picture(s) may appear in publications and promotional materials, such as, but not limited to, Church Newsletter, PowerPoint Presentations, Church’s websites www.searoadchurch.org and www.searoadchurch.churchcenter.com; church brochures, postcards, and flyers.

Yes

Other Comments/Notes

Medical and Photo Release Form

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