Ascension Children's Ministry Registration
Please complete one per child.
CHILD'S INFORMATION
Child's Full Name
First & Middle Name
Last Name
Any Preferred Name/Nickname?
Child's Date of Birth
-
Month
-
Day
Year
Child's Age
Child's Grade In School
Name of school child attends
School Name Here.
.
Home Phone
Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Email For Us To Contact You
Second Email (if another one)
Parent/Guardian #1 Name
First Name
Last Name
Parent/Guardian #1 Cell Number
Format: (000) 000-0000.
Parent/Guardian #2
First Name
Last Name
Parent/Guardian #2 Cell Number
Format: (000) 000-0000.
Authorized people to pick up my child (must be 18 years or older):
Is there any custodial information that we should be aware of? If so, please list below:
Do you have a church home? If not, would you like to be contacted to learn more about our church?
Yes
No
MEDICAL HISTORY
Are there any allergies we need to be aware of?
Are there any special considerations that we need to be aware of?
Is your child taking any medications? If Yes, please list under "Medication Details":
Yes
No
Medication Details
Is there anything else we should be aware of about your child?
EMERGENCY CONTACT INFORMATION
Every effort will be made to contact the parents or guardian of the child before treatment is given.
Relationship to child:
blanks
.
Name
First Name
Last Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Info
I give my permission for any photos taken of my child to be used at the church or on the Church's website/social media channels.
Yes
No
I am available to periodically help with Children's Ministry and here are a few ideas of areas I'm interested in helping with:
CONSENT TO TREAT AND RELEASE OF LIABILITY:
In consideration for being accepted by the Church of the Ascension for participation in our Children’s program, we (I), being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 18 years of age or older) do hereby release, forever discharge and agree to hold harmless The Episcopal Church of the Ascension and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described activity. Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify said organization, its directors, employees and agents, for any liability sustained by said organization as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. We (I) are the parents(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him or her to participate fully in our Children’s program, and the activities done there, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
MEDICAL INFORMATION FOR EMERGENCY USE
Medical Insurance Provider
Policy Number
Doctor's Name
Doctor's Office Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: