Parent/Guardian Name *

First Name

Last Name

Contact Phone *

(###)

###

####

Emergency Contact Name *

(Someone we should contact, if parent/guardian above is not available.)

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Child 1 Name *

First Name

Last Name

Child 1 Date of Birth *

MM

DD

YYYY

Child 2 Name

First Name

Last Name

Child 2 Date of Birth

MM

DD

YYYY

Child 3 Name

First Name

Last Name

Child 3 Date of Birth

MM

DD

YYYY

Child 4 Name

First Name

Last Name

Child 4 Date of Birth

MM

DD

YYYY

Child 5 Name

First Name

Last Name

Child 5 Date of Birth

MM

DD

YYYY

Child 6 Name

First Name

Last Name

Child 6 Date of Birth

MM

DD

YYYY

Photo/Video Release *

Ambassador Church has my permission to use my or my child’s photograph publically to promote outreach ministries of the church. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I Agree

I Do Not Agree

Future Contact *

May we add you to our email list? We would just like to let you know when we have special events, like VBS. We will never spam you with emails all the time, or share your contact information with any other organizations.

Sure

No Thanks