Home Church Please tell us which church you regularly attend, OR list the organization through which you are registering for this event (i.e. Christian Community Center) For which event are you registering? * CITY KIDS: Pots and Paint (Saturday, May 12) Please list all children registering for this event. Child 1 First Name Last Name Age Birth Date MM DD YYYY Grade Last Completed Child 2 First Name Last Name Age Birth Date MM DD YYYY Grade Last Completed Child 3 First Name Last Name Age Birth Date MM DD YYYY Grade Last Completed Child 4 First Name Last Name Age Birth Date MM DD YYYY Grade Last Completed In the event that my child becomes ill or injured, I authorize the accompanying adults to contact the parent and/or legal guardian and follow his/her instructions. Mother’s Name First Name Last Name Phone Number (Home) (###) ### #### Phone Number (Cell) (###) ### #### Father’s Name First Name Last Name Phone Number (Home) (###) ### #### Phone Number (Cell) (###) ### #### Parent Email Please list the email address you check most often. We will be sending you important information about this event. Address Address 1 Address 2 City State/Province Zip/Postal Code Country If the parent or legal guardian is not available, please contact the following person and follow his/her instructions. Emergency Contact Name First Name Last Name Relationship to Child Phone Number (Home) (###) ### #### Phone Number (Cell) (###) ### #### If no one can be reached in the event of an EMERGENCY, I hereby give my permission to the physician selected by the adult leader to hospitalize, secure proper treatment for, and to order injection, anesthesia for surgery to my child. Primary Physician Name First Name Last Name Phone Number (###) ### #### Medical Insurance Carrier Policy Number Please list any known allergies, dietary restrictions, medical conditions or drug reactions: Specify child if you are registering multiple Photo Release I give permission for my child’s photo to be taken and potentially used in church communications (i.e., web site) Parent Signature Please provide your electronic signature. First Name Last Name Today’s Date MM DD YYYY Thank you!
