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CHATHAM BAPTIST CHURCH

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ADVENTURE WEEK REGISTRATION

Child's First Name (and Preferred Name)*

Last name*

Child's Birth Date*

Month

Day

Year

Grade for 2025*

4 yo

K

1st

2nd

3rd

4th

5th

6th

7th

8th

Parent Name*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Phone 2

Email*

Does your family attend church?

Yes

No

If Yes, what church?

How often do you attend church?

Weekly

Often

Seldom

Never

Would you like more information about Chatham Baptist Church?

Yes

No

If yes, by email?

Yes

No

Does your child have any allergies or diet restrictions?*

Yes

No

If Yes, please list any allergies or restrictions. In the case of allergies, please state the severity using the following: (Life-Threatening, Moderate, Occasional, Mild)*

Does your child have an EpiPen?*

Yes

No

Is there any other important information you need to share with us?

EMERGENCY CONTACTS

Name*

Relationship to Child*

Phone*

Name

Relationship to Child

Phone

PHOTO & VIDEO RELEASE

By submitting this form, I grant permission for my child to be photographed & videotaped while attending Adventure Week. I understand that pictures and videos may appear in local media publications, and/or in publications of Chatham Baptist Church. I also understand that no personal information will be given in any of the aforementioned publications.

LOCATION

Phone: (217) 483-2471

Email: chathambcoffice@gmail.com

Address: 1500 E. Walnut St.
Chatham, IL 62629

CONNECT

HOURS

Mon-Sat: 8am-4pm

Sun: 8am-12pm

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