Brick Church Childcare | Brick Church

Child's First Name *

Child's Last Name *

Parent/ Guardian Name *

First

Last

Parent/ Guardian Phone Number *

Parent/ Guardian Email *

How old is your Child? *

Is you child potty-trained? *

Please List all all adults authorized to pick up your child at the end of the service

Does your child have any allergies? *

Please detail your child's allergies

Does your child use an Epi Pen? *

PLEASE NOTE: No outside food or drink is allowed in childcare. However, in case of emergency, your child will need to have the pen with him/her at Sunday Church School each time he or she comes. We cannot store this medicine at Brick, but it will need to be made available to the teachers each week. Along with the pen, parents need to submit the medical instructions for the child in case of an allergic reaction If other medicines are needed for allergic reactions, they will need to be provided as well each week.

Do you, the parent/guardian, grant our childcare and Sunday Church School volunteers authority to use this pen if your child is having an allergic reaction? *

I hereby GRANT or DO NOT GRANT (choose one) the Brick Presbyterian Church in the City of New York the right to use photographs and/or video of me and/or the child or children listed in this application for publications, electronic reproductions (website and social media) and/or promotional materials or any other purpose and in any manner. Further I attest that I am the parent or legal guardian of the child or children listed below. I also acknowledge that participation is completely voluntary. The Brick Presbyterian Church will not identify individuals in external media publications. Children names and contact information will not be listed. According to our Safe Sanctuary Policy, photos of children will not be used in external publications without parental consent. Please refer to our Brick Presbyterian Church Web Policy for publication policies. I hereby release the Brick Presbyterian Church in the city of New York from all claims and liability relating to said photographs, video or quotes. *

Please detail anything else we should know

Child's Name

First

Last