Step 1 of 4 25% Child's DetailsChild Information*NameGenderBirthday (MM/DD/YY)AgeLast grade completed Use the + sign to add more than one child. Parent(s) DetailsName of parent(s)*Phone 1*Phone 2Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Medical & Emergency InformationAllergies and/or medical conditions Emergency contact*Relationship to child*Phone* Final QuestionsHome Church*Does your child have a friend they would like to be placed with? If so, who?LIABILITY RELEASE AND PHOTOGRAPHY / VIDEO AUTHORIZATION* I Agree In the event of an emergency, I understand that all will be done to contact me or the emergency contact named above. However, if neither can be reached, I give full permission to a representative of Bastrop Christian Outreach Center (BCOC) to seek medical attention in my absence for the child registered on this form. I also hereby assume all risk, known or unknown, for the child registered on this form, in connection with their attendance and participation in this event at BCOC. I acknowledge that participation in this event at BCOC is voluntary and therefore I FULLY RELEASE and discharge Bastrop Christian Outreach Center, its pastors, employees, directors, and volunteer workers, from any and all liability in connection with any activities carried on at BCOC. I further acknowledge that any child registered on this form may be photographed or captured on video during the program and activities. I hereby grant full permission to BCOC to use photographs or videos-in print, electronic, online, or other public media-of the child registered on this form and further release BCOC from any and all liability connected with the authorized use of words and image of the child registered on this form.NameThis field is for validation purposes and should be left unchanged.