GRACEKIDS / KIDSCUB REGISTRATION 2021-2022
Today's Date
/
Month
/
Day
Year
Date
Parent or Guardian (If Parent/Guardian is not here, name of Adult who brought the child, and relationship to child)
*
Parent/Guardian/Accompanying Adult Email Address(es)
*
example@example.com
Best contact while the child is in class
*
Mom's cell phone number.
Best contact while the child is in class
*
Dad's cell phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CHILD 1
Name
*
Gender
Please Select
M
F
Child 1 birth date
-
Month
-
Day
Year
Date
Age
*
Grade
*
Allergies / Reaction
*
Any other information about your child that may be helpful to the caregivers/teaching team?
Does your child receive any therapeutic services or have an IEP or 504 plan?
*
Yes
No
CHILD 2
Name
Gender
Please Select
M
F
Child 2 Birth Date
-
Month
-
Day
Year
Date
Age
Grade
Allergies / Reaction?
Any other information about your child that may be helpful to the caregivers/teaching team?
Does your child receive any therapeutic services or have an IEP or 504 plan?
Yes
No
CHILD 3
Name
Gender
Please Select
M
F
Child's birth date
-
Month
-
Day
Year
Date
Age
Grade
Allergies / Reactions?
Any other information about your child that may be helpful to the caregivers/teaching team?
Does your child receive any therapeutic services or have an IEP or 504 plan?
Yes
No
Permission Slip / Parental Consent / Medical Release
By signing below, I give my permission for my children to attend and participate in any activities sponsored by GraceKids and/or KidsClub of Grace bible Church, Ann Arbor, MI. In case of medical emergency, I authorize an adult, in whose care the minor has been entrusted, to sign for and/or administer any necessary medical or dental care for my children named above.
*
Authorized signature
Clear
Permission to use photographs or videos:
By signing above, I grant to Grace Bible Church, its representatives and employees the right to take photographs and/or videos of the children named above in connection with church activities, including GraceKids and KidsClub. I authorize Grace Bible Church, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Grace Bible Church may use such photographs and/or videos with or without my children's names for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and internet content.
To refuse permission to use photographs/videos, initial below:
Initial here to refuse photo permission.
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