Open Door Baptist Church

Friends Class/Special Needs Ministry

Registration Form

Personal Data

Name:  ______________________________________________  Birth Date:  ______________________

Address:  _____________________________________________________________________________

               _____________________________________________ Phone:  ________________________

               Address is _______  Family home             _______  Group home      ______ Other    (check one)

Parent(s)/Legal Guardian(s):  ___________________________________________________________

Address:  ____________________________________________  Phone:  ________________________

Other Phone Numbers in Case of Emergency:  _______________________________________________

Alternative Contact Person: ______________________________________________________________

Phone Number for Alternative Contact Person: _______________________________________________

 

Security Measures*

Names of persons who may bring or pick up this friend:  ______________________________________

Contact Phone Number:  ________________________________________________________________

Names of persons who may not have access to this friend:   ___________________________________

*Parent(s)/legal guardian(s) will notify Open Door Baptist Church in writing if and when these security measures change.

 

Other Information

Allergies or Physical Limitations: __________________________________________________________

Special Instructions for Handling Allergies or Physical Limitations:  _______________________________

_____________________________________________________________________________________

Dietary Restrictions:  ___________________________________________________________________

Behavioral Concerns:  __________________________________________________________________

Personal Care Concerns:   _______________________________________________________________

 

Special Interests

Favorite Activities, Places, etc:  ___________________________________________________________

Any Additional Comments:   ______________________________________________________________

_____________________________________________________________________________________

 

Permission:  I give permission for ___________________ (name of friend) to attend the Special Needs Ministry at Open Door Baptist Church.  I also give Open Door Baptist Church permission to seek medical help if it should become necessary.

_____________________________________________                         ____________________________________

                       Signature of Parent or Guardian                                                                           Date