Celebrate Recovery Child Information

Child's Name __________________________ Age____

Parent's or Guardian's name (Only those attending Celebrate Recovery)
______________________________________________

______________________________________________

Group normally attend____________________________

____________________________

Emergency Contact Person _______________________

______________________________________________

Allergies ______________________________________

Home Address_______________________________________

______________________________________________

Tel. Hm _______________Tel. Cell ________________

I have read and agree to the Celebrate Recovery Childcare Guidelines.

Signature ____________________________________

Date ___________________