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)
Please list all children registering for this event.
Child 1
Child 1
Birth Date
Birth Date
Child 2
Child 2
Birth Date
Birth Date
Child 3
Child 3
Birth Date
Birth Date
Child 4
Child 4
Birth Date
Birth Date
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
Mother’s Name
Phone Number (Home)
Phone Number (Home)
Phone Number (Cell)
Phone Number (Cell)
Father’s Name
Father’s Name
Phone Number (Home)
Phone Number (Home)
Phone Number (Cell)
Phone Number (Cell)
Address
Address
If the parent or legal guardian is not available, please contact the following person and follow his/her instructions.
Emergency Contact Name
Emergency Contact Name
Phone Number (Home)
Phone Number (Home)
Phone Number (Cell)
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
Primary Physician Name
Phone Number
Phone Number
Specify child if you are registering multiple
Photo Release
Parent Signature
Parent Signature
Please provide your electronic signature.
Today’s Date
Today’s Date