Preschool Splash & Play Registration Form

Preschool Splash & Play (3 to 5 yr olds)

Tuesdays, from July 19 to Aug 16 - 6 to 7 PM at Shady Grove Picnic Shelter.
Full Name *

First Name Last Name
Age *
Age (3-5)
Parent/Guardian *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Emergency Contact (If Different from above)

First Name Last Name
Phone Number

Area Code Phone Number
Special Needs/ Allergies *
I hereby grant permission for the above listed child to attend Preschool Splash and Play, a program of Shady Grove United Methodist Church. In my capacity as self, spouse, parent or legal guardian, I am aware that there are certain normal and reasonable risks associated with participation in water activities. I hereby waive any right that I, my spouse, or said minor child may have to sue Shady Grove Church or any of their employees, as a result of any and all injuries, damages, and/or losses sustained during Splash and Play at Shady Grove Picnic Shelter.

I further agree to hold Shady Grove United Methodist Church and any of their employees blameless and I agree to bear the cost of their legal defense if any suit of legal or equitable action is brought against any of them as a result of any and all injuries, damages, or losses suffered by me, my spouse, or my child while participating. Finally, I hereby appoint Leigh Tuttle, Children’s Pastor, or emergency personnel on duty to act in place of myself or my spouse to hospitalize and/or secure proper treatment and/or order injection or anesthesia or surgery for my child if I, my spouse, or my child is unable to act on our own behalf or if I or my spouse are unable to be notified of above medical treatment beforehand.
Parent Signature *
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Preschool Splash & Play (3 to 5 yr olds)