Foster Nights WEDNESDAY | December 13 DINNER PROVIDED FOR ALL FAMILIES MEETING (Programming available for all ages): 5:00p-7:15p FOSTER SUPPORT NIGHT REGISTRATION Step 1 of 3 - PARENT / GUARDIAN INFORMATION 33% Parent / Guardian #1First Name* Last Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Allergies*(If none, type N/A)Please list up to two adults (other than parent/guardian) who are authorized to pick up your child. If there is none authorized, please type N/A.*(If none, type N/A)Parent / Guardian #2First Name Last Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail Allergies(If none, type N/A) Child #1First Name* Age* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade (If Applicable)*Not In SchoolPre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAllergies*(If none, type N/A)Does your child have any medical concerns that may affect your child while in our care?*In order to provide the best care, does your child have any special needs or challenges for us to be aware of?*Child #2First Name Age Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade (If Applicable)Not In SchoolPre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAllergiesDoes your child have any medical concerns that may affect your child while in our care?In order to provide the best care, does your child have any special needs or challenges for us to be aware of?Child #3First Name Age Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade (If Applicable)Not In SchoolPre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAllergiesDoes your child have any medical concerns that may affect your child while in our care?In order to provide the best care, does your child have any special needs or challenges for us to be aware of?Child #4First Name Age Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade (If Applicable)Not In SchoolPre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAllergiesDoes your child have any medical concerns that may affect your child while in our care?In order to provide the best care, does your child have any special needs or challenges for us to be aware of?Child #5First Name Age Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade (If Applicable)Not In SchoolPre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAllergiesDoes your child have any medical concerns that may affect your child while in our care?In order to provide the best care, does your child have any special needs or challenges for us to be aware of?Additional ChildrenWill you be bringing more than 5 children?YesNoIf yes, please fill out the appropriate amount of forms belowChild #6Please include name, birthday, grade (if applicable), and please list any allergies, medical concerns, or special needs.Child #7Please include name, birthday, grade (if applicable), and please list any allergies, medical concerns, or special needs.Child #8Please include name, birthday, grade (if applicable), and please list any allergies, medical concerns, or special needs.Child #9Please include name, birthday, grade (if applicable), and please list any allergies, medical concerns, or special needs.Child #10Please include name, birthday, grade (if applicable), and please list any allergies, medical concerns, or special needs. Emergency Contact Information #1Emergency Contact: First Name* Emergency Contact: Last Name* Emergency Contact: Phone Number*Relationship to Child(ren)* Emergency Contact Information #2Emergency Contact: First Name* Emergency Contact: Last Name* Emergency Contact: Phone Number*Relationship to Child(ren)* AGREEMENTSAWANA/WEDNESDAY NIGHT ACTIVITY AGREEMENT* I agree to send my children to the age-appropriate activity scheduled for them on this evening. If I wish to make special arrangements for my child, I will contact Kim Barnette (704-907-7387).The following activities are provided during our Foster Support Group AWANA (Ages 3 through 5th Grade) | Children are invited to play games, make friends, and learn about God's Word. This takes place in the Family Ministry Center, located at the back of the campus (where you check-in). Student Bible Study (6th through 12th Grade) | Teenagers are invited to the Student Center (located at the front of the campus) for Bible Study, where they are divided into grade groups and work with an older leader to study God's Word.Children and Student Medical/Liability Release Form* I agree to the Medical Release policy.LIABILITY RELEASE: I, the parent/guardian submitting this form, do hereby release, acquit, hold harmless and forever discharge South Point Baptist Church (henceforth referred to as SPBC), its agents, servants, and employees, and all persons, natural or corporate, in privities with them or any of them, from any and all claims or causes of action of any kind whatsoever, including but not limited to actions, suits and/or claims for any bodily injuries, death, or property damage which may be sustained by the child listed above while participating in any Family Ministry activity, or activities, (including travel to and from such activities) resulting from the negligence of lack of care due or claimed to be due to the conduct of any agent, servant, or employee of SPBC, for any and all activities. MEDICAL RELEASE: I, the parent/guardian submitting this form, give and grant unto any licensed medical doctor or hospital my consent and authorization to x-ray or rend such aid, treatment, or care to said child as in the judgment of doctor or hospital, may be required, on an emergency basis, in the event said child should be I injured or stricken ill while participating in an SPBC sponsored event. It is further understood that any expense incurred will be paid for by insurance or the parent/guardian. I also understand that if the child needs to be sent home for any reason( i.e. illness, injury, or disciplinary), I will be contacted at one of the numbers above, and I will be responsible for any and all expenses incurred. Worship | 8:30a & 10:45a Bible Study | 9:45a (704) 825-9516 124 Horsley Ave, Belmont, NC 28012