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Home
City Church Livestream
About
Staff
Values
Worship Time & Location
Caring
Get Involved
Events
Community Groups
City Kids
Serve
Give
Summer Missions
Worship Resources
Blog
Sermons
Recommended reading
Music
Counseling
Contact
City Kids Event Registration
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!