Welcome to the Teen Center

at First Baptist Church of Brunswick

Please complete the form below to give your child permission to participate in activities at The Teen Center at First Baptist Church if Brunswick.

Please complete a form for each child you are giving permission.

Name(Required)

First Last

Email(Required)

Phone(Required)

Name(Required)

First Last

Email(Required)

Phone

Age(Required)

Date of Birth(Required)

Grade in School(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Is your youth presently being treated for an injury or sickness or taking any medication?(Required)

If yes, please explain(Required)

Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.(Required)

Asthma

Diabetes

Hay Fever

Heart Murmur

Kidney Disease

Seizure Disorder

Other

(Please check all that apply.)

Please explain(Required)

If other, please explain details(Required)

Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity?(Required)

If yes, please explain(Required)

Signature

3 East A St.
Brunswick, MD 21716
[P] (301) 889-9820