Child's Name (required)
Child's Age (required) weeksmonthsyears
Will he/she be eating pizza? YesNo
Parent/Guardian's Name (First & Last)
Parent/Guardian's Email Address
Medical concerns, special needs or food allergies
Emergency Contact (parent/guardian preferred) Name
Phone
Medical Release As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician of the minor(s) registered above in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life or cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a resonable effort has been made to reach me. The undersigned assumes the responsibility for any cost connected with such treatment. I hereby agree to release Southside Baptist Church and its staff and volunteers from liability in the event of injury. A copy of this authorization can be used as the original.
Medical Insurance Provider
Medical Insurance ID
By checking this box, you verify that this form is completed and submitted of your free will with the sole purpose of authorizing medical treatment under emergency circumstances in your absence.
Let us know what we can do for you - the more details the better!
Today's Date *
Name *
Email *
Phone Number *
Ministry Team/Area *
Event Name *
Is this event recurring? * YesNo
When does this event recur (daily, 1st Sunday of each month, weekly on Wednesdays, etc)?
Event Starting Date *
Event Ending Date *
Starting Time *
Ending Time *
Location of Event * Note: Food and drink setup is not allowed in the Nursery area.
Event Fee? * YesNo
If yes, how much?
Childcare Available * YesNo
Tables Needed? * YesNo
If yes, how many? Round Tables: Long Tables:
Chairs Needed? * YesNo
If yes, how many chairs?
Bus Needed? * NoOne BusBoth Buses
If using a bus/buses, who will be the driver?
Event Details * (Please include anything that needs to be included in communications requested below.)
Promotional Needs (please check all that apply) Bulletin ArticleE-news ArticleAnnouncement SlideSocial Media Post/EventRegistration @ Info TableOnline RegistrationPostcard (Mailer)Flyer (8.5x11)Poster (11x17)TicketsEvent Program
Please list quantities & date needed for anything checked above or additional promotional materials you may need for the event:
This is where you can upload photos/graphics/bios, etc.
Attach a File
