Girls’ Brigade
Child’s Information Form

Child's Name (required)

Birth Date

Street Address (required)

Postal Code (required)

Telephone Number (required)

Mother's Email (required)

Mother's Name (required)

Mother's Work Place

Mother's Work Number

Mother's Home Number

Mother's Cell Number (required)

Father's Email (required)

Father's Name (required)

Father's Work Place

Father's Work Number

Father's Home Number

Father's Cell Number (required)

With whom does the child live?

Names of siblings attending the Girls' Brigade Company

Emergency Contact (should you not be available)

Name (required)

Relationship (required)

Emergency Contact's Work Number

Emergency Contact's Home Number

Emergency Contact's Cell Number (required)

Allergies (required)

Medications presently taking:

Will your child need to bring medication to Girls' Brigade? (required)

If yes, a written permission slip with instructions must be signed by you and the leader.

Does your child suffer from any medical condition? (required)

If yes, please state:

Do you attend church?

Church Name

Is there any other information we should have?

Girls' Brigade Company (required)

Please contact us immediately should there be any changes to this information given.