Family Ministry | Intake Form

This form is used by Christ Church Winston-Salem to gather information information about your child(ren) so that we can serve them well in our various ministries to families. Please let us know if there are any changes to this information throughout the year.

Your name *

Last name

Email address *

Child's Information

Child 1 First & Last Name *

Child 1 Nickname, if applicable

Child 1 Date of Birth *

Child 1 Gender *

Male

Female

Child 2 First & Last Name

Child 2 Nickname, if applicable

Child 2 Date of Birth

Child 2 Gender

Male

Female

Child 3 First & Last Name

Child 3 Nickname, if applicable

Child 3 Date of Birth

Child 3 Gender

Male

Female

Would you like your child(ren) to be listed on the prayer calendar for our church? *

Family Information

Parent/Guardian 1 Name *

Parent/Guardian 1 Phone Number *

Email *

Parent/Guardian 2 Name

Parent/Guardian 2 Phone Number

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Emergency Contact

If possible, preferably another attendee of Christ Church

First and Last Name *

Relationship to Child *

Emergency Contact Phone Number *

For the safety of your child, list any alternate people (other than parents/guardians) who are authorized to pick up your children. List older siblings if you would like them to pick up younger siblings. *

Please list all names here:

Medical Information

Does any of your children have any severe allergies? *

Yes

Do any of your children have a condition that could require emergency medication? *

(If yes, please send the medication with your child each week)

Yes

Will your child(ren) require any special accommodation that is important to their care while served in our minstry? *

Yes

Media Release

I give permission for photographs with personally identifying information of my child/charge to be publicly posted on church-affiliated websites, publications, and digital communications (i.e. church website, church Facebook page). *

Yes

Please type your name as an electronic signature *

Christ Church
info@christchurchws.org
3363313301

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