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!

General Information

Today's Date *

Name *

Email *

Phone Number *

Ministry Team/Area *

Event Information

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.)

Communication Request

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:

File Upload

This is where you can upload photos/graphics/bios, etc.

Attach a File

Submit Your Request