St. Matthews United Methodist Church
Sunday, November 18, 2018
• Growing In Love For God & Love For Others •
GENERAL  INFORMATION
Child's Name    Date of Birth   
Parent/Guardian Name 
What grade will this child start in the fall? 
Does this child require a booster seat? 
(please check one)    This child can swim      This child needs a flotation device
CONTACT  INFORMATION
Home Address / City    Apt # 
Mailing Address (if different) 
Best Daytime Phone #   
Alternate Daytime Phone #   
E-mail Address 
MEDICAL  INFORMATION
Over-the-counter medications this child IS allowed (check all that apply):
Aspirin         Tylenol         Ibuprofen         Benadryl
Hydrocortisone         Neosporin         Sunscreen         Insect Repellent
Please list any known allergies, current medications, or other relevant medical information below.
IN CASE OF AN EMERGENCY WHERE PARENT/GUARDIAN CANNOT BE REACHED
Emergency Contact Name 
Emergency Contact Phone # 
Relationship To This Child 
DISMISSAL  AUTHORIZATION
Other than parents/guardians listed, is anyone else authorized to pick up this child?