Child's Name *

First Name

Last Name

Birthday

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Media Release *

I hereby grant permission for my child/children’s photograph to be included in the church publications, local press, video, outreach brochures and church website. It is our policy not to identify children by name.

Yes, I agree to the above Media Release.

No, I would prefer photographs of my child(ren) to not be published.