Kids Club

Parent Name

Parent Email

This address will receive a confirmation email

Parent Phone

Address

How did you hear about us?

Name of home church (if applicable)

Child 1 Information

Name

Birthdate (including year)

Grade

Any food allergies/ medical restrictions we should know about?

Child 2 Information

Name

Birthdate (including year)

Grade

Any food allergies/ medical restrictions we should know about?

Child 3 Information

Name

Birthdate (including year)

Grade

Any food allergies/ medical restrictions we should know about?

Child 4 Information

Name

Birthdate (including year)

Grade

Any food allergies/ medical restrictions we should know about?

Emergency Contact

In the case of an emergency and if the parent or guardians listed above cannot be reached in a reasonable period of time, the individuals listed below may be contacted, given notification of the emergency, and be authorized to provide instructions for the actions to be taken.

Contact's Name

Contact's Phone

Alternate Phone

Relationship to Student

Relative Friend

Release of Liability

I acknowledge and understand there are inherent risks associated with some Countryside Christian Church activities. I will assume the risks associated therewith, whether known or unknown to me at this time. I recognize that my student's attendance at a Countryside Christian Church sponsored event is a privilege and as a consideration for this privilege, I release Countryside Christian Church including it's employees, agents and trustees, from responsibility for my student's accidental physical injury, including death or illness while at a sponsored trip or activity or during travel to and from events. This release is intended to incude all claims made by my family, estate, heirs, personal representatives or assigns.

Parent Initials

Media Consent

I hereby grant permission to Countryside Christian Church the right to take, use, reproduce, and/or distribute photographs, films, video, and sound recordings of my student, without compensation or approval of rights, for use in materials created for the purposes of promoting the activites of Countryside Christian Church.

Parent Initials

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the student named above may be in need of first aid or ememrgency medical treatment as a result of an accident, illness, or other health condition or injury. I do hearby give permission for agents of Countryside Christian Church to seek and secure any needed medical attention or treatment for the student named above, including hospitalization, if in the agent's opinion such need arises. In doing so, I agree to pay all fees and costs arising from this medical treatment. I also give permission for attending physician(s) and other medical personnel to administer any needed medical treatment and again, I agree to pay for the medical treatment.

Parent Initials

Kids Club

Description

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