Address: 130 W Seminary Ave, Lutherville, Maryland, 21093, US
Telephone: 410-252-2711

Child's Name:*
First Last
Child's Nickname (if Applicable):
Parent or Guardian Name:*
First Last
Parent or Guardian Name:
First Last
Child's Date of Birth:*
Date Format: MM slash DD slash YYYY
Grade in school:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Preferred Method of Communication:
- Call
- Text
- Email
Please list any allergies or other conditions we should be aware of (food reactions, physical challenges, ADD/ADHD, etc.):
Emergency Contact Name:*
First Last
Phone # for Emergency Contact:*
Comments:
Because we love taking pictures at Holy Comforter, we need your permission to photograph your child. I grant to the Church of the Holy Comforter and the Episcopal Diocese of MD, its representatives and employees, the right to take photographs of my child and my property. I authorize CHC and the Diocese, its assignees and transferees the right to copyright, use and publish the same in print and/or electronically. I agree that such photographs of my child may be used with or without their first name and for any lawful purpose, including such purposes as publicity, illustration, advertising, Web content, etc. I have read and understand the above.*
- Yes- I agree
- No- I do not agree
Signature of Parent or Guardian*
Date*
Date Format: MM slash DD slash YYYY