The Point is to Serve - KidsServe Emergency Contact

Parent/Guardian Information

First Name

Last Name

Email

Phone Number

Phone Number 2

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Child Information

Child First Name

Child Last Name

Grade

Birthdate

Gender

Allergies or Medical Conditions

Add another child

Yes

No

Check-Out + Media Release

Adults (other than parent/guardian) authorized to pick up child from KidsServe

Permission for self check-out (for students ages 10+)

Yes, the child listed on this form is at least 10 years old and has permission to check himself/herself out of KidsServe programming without an adult

No, my child does not have permission to self check-out

Not Applicable (child not old enough)

Media Release: My child can be photographed, and I authorize photographs to be used for KidsServe or The Point is to Serve educational or promotional purposes.

Yes

No

Child Information

Child First Name

Child Last Name

Grade

Birthdate

Gender

Allergies or Medical Conditions

Add another child

Yes

No

Check-Out + Media Release

Adults (other than parent/guardian) authorized to pick up child from KidsServe

Permission for self check-out (for students ages 10+)

Yes, the child listed on this form is at least 10 years old and has permission to check himself/herself out of KidsServe programming without an adult

No, my child does not have permission to self check-out

Not Applicable (child not old enough)

Media Release: My child can be photographed, and I authorize photographs to be used for KidsServe or The Point is to Serve educational or promotional purposes.

Yes

No

Add another child

Yes

No

Child Information

Child First Name

Child Last Name

Grade

Birthdate

Gender

Allergies or Medical Conditions

Add another child

Yes

No

Check-Out + Media Release

Adults (other than parent/guardian) authorized to pick up child from KidsServe

Permission for self check-out (for students ages 10+)

Yes, the child listed on this form is at least 10 years old and has permission to check himself/herself out of KidsServe programming without an adult

No, my child does not have permission to self check-out

Not Applicable (child not old enough)

Media Release: My child can be photographed, and I authorize photographs to be used for KidsServe or The Point is to Serve educational or promotional purposes.

Yes

No

Add another child

Yes

No

Any comments/questions?

Signature

KidsServe Emergency Contact Form

Parent/Guardian Information

Child Information

Check-Out + Media Release

Child Information

Check-Out + Media Release

Child Information

Check-Out + Media Release

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