Gethsemane Church | Pekin IL Church Near Peoria, Tremont & East Peoria

Child Information

Add each child who will attend Children's Ministry and/or ride the bus.

Child 1

Child's Name *Child's Date of Birth *

Allergies, medical conditions, medications, or special needs for this child

Parent/Guardian Information

Parent/Guardian Name *Phone Number *

Parent Email Address *Address *

Emergency Contact Information

Please provide two emergency contacts.

Contact 1 Name *Contact 1 Phone *Relationship *

Contact 2 Name *Contact 2 Phone *Relationship *

Medical Authorization & Emergency Treatment Consent

Medical details for each child can be listed above under Child Information.

EVERY BOX MUST BE CHECKED IN ORDER FOR THIS FORM TO BE SUBMITTED.

In the event of an emergency and I cannot be reached, I authorize Gethsemane Church staff, bus workers, and volunteers to obtain emergency medical treatment for my child/children as deemed necessary.

Media Release & Ministry Permission

EVERY BOX MUST BE CHECKED IN ORDER FOR THIS FORM TO BE SUBMITTED.

I acknowledge the photo, video, and media release for church-related purposes, including the church website, social media pages, printed materials, presentations, and ministry publications.I give permission for my child/children to attend Gethsemane Church services, classes, activities, and transportation provided by the Gethsemane Church Bus Ministry.I have read every word carefully and understand the requirements and expectations of the Gethsemane Church Children's and Bus Ministry.I agree to ensure my child/children follow these guidelines.

Digital Signature

Parent/Guardian Digital Signature *Date *

Before You Submit

Child Information

Child 1

Parent/Guardian Information

Emergency Contact Information

Medical Authorization & Emergency Treatment Consent

Media Release & Ministry Permission

Digital Signature