Hillside Kids Registration Form

1
Child's Legal Name* This field is required.
First Name
Last Name
2
Name Your Child Responds To?If different than above
3
Child's Birthdate* This field is required.
Date
Year
Month
Day
4
Child's Address* This field is required.
Street Address
Street Address Line 2
City
Province
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Does Your Child Have Any Allergies / Medical Conditions we would need to know about?* This field is required.
YESNO
6
If YES, please list the Allergies / Medical ConditionsIf NO feel free to click 'NEXT'
Huge
Large
Normal
Small
Ok
Ok
7
Is your child bringing any medication with them?* This field is required.
YESNO
8
If YES, please list the Allergies / Medical ConditionsIf NO feel free to click 'NEXT'
Huge
Large
Normal
Small
Ok
Ok
9
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our team should be aware of?* This field is required.
YESNO
10
If YES, please explain concerns or limitations:
Huge
Large
Normal
Small
Ok
Ok
11
Is there any legal custody agreements that we should be aware of for this child?* This field is required.
YESNO
12
If YES, please explain the legal custody agreements:
Huge
Large
Normal
Small
Ok
Ok
13
Medical Release* This field is required.I/we, the parents or guardians named below, authorize one of the Hillside Church Ministry Staff or Volunteers to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.
YESNO
14
Primary Contact Name* This field is required.This is the person registering the child for Hillside Kids
First Name
Last Name
15
Relationship To Child* This field is required.
Mother
Father
Guardian
Other
16
Primary Contact Phone Number* This field is required.
Please enter a valid phone number.
17
Primary Contact Email* This field is required.
example@example.com
18
Secondary Contact NameIt is not required to have a Secondary contact. Only registered contacts will be authorized to pick the child up from Hillside Kids. A contact must be at least 16 years of age to pick up a child from Hillside Kids.
First Name
Last Name
19
Relationship To Child
Mother
Father
Guardian
Other
20
Secondary Contact Phone Number
Please enter a valid phone number.
21
This Contact Is Authorized to pick this child up from Hillside Kids
YESNO
22
Alternate Contact NameIt is not required to have a alternate contact. Only registered contacts will be authorized to pick the child up from Hillside Kids.A contact must be at least 16 years of age to pick up a child from Hillside Kids.
First Name
Last Name
23
Relationship To Child
24
Alternate Contact Phone Number
Please enter a valid phone number.
25
This Contact Is Authorized to pick this child up from Hillside Kids
YESNO
26
Today's Date
Date
Year
Month
Day
27
ReleaseI/we, named above undertake and agree to indemnify and hold blameless the Ministry Staff and Volunteers of Hillside Church, its' Pastors and Leadership from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Hillside Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in events of Hillside Church.
YESNO
Should be Empty: