PPT KIDS CLUB REGISTRAITON FORM 2025-2026

PPT KIDS CLUB REGISTRATION 2025-2026 SEASON

PLEASE NOTE: There are 6 Pages to the form (to register up to 5 children) Please go through to the end and click on the "SUBMIT" button to complete the form. THANK YOU
FIRST Child's Name*

First NameLast Name
FIRST Child's Birthday*

MonthDayYear
Date
FIRST Child's HEALTH CARD NUMBER*
Special Medical Concerns, Allergies or Medications (FIIRST CHILD)

PLEASE NOTE: There is room to register 5 children. If you do not have 5 kids just skip past and fill out the information at the end and click on 'SUBMIT' or your form will not send.
SECOND Child's Name

First NameLast Name
SECOND Child's Birthday

MonthDayYear
Date
SECOND Child's HEALTH CARD NUMBER
Special Medical Concerns, Allergies or Medications (SECOND CHILD)

THIRD Child's Name

First NameLast Name
THIRD Child's Birthday

MonthDayYear
Date
THIRD Child's HEALTH CARD NUMBER
Special Medical Concerns, Allergies or Medications (THIRD CHILD)

FOURTH Child's Name

First NameLast Name
FOURTH Child's Birthday

MonthDayYear
Date
FOURTH Child's HEALTH CARD NUMBER
Special Medical Concerns, Allergies or Medications (FOURTH CHILD)

FIFTH Child's Name

First NameLast Name
FIFTH Child's Birthday

MonthDayYear
Date
FIFTH Child's HEALTH CARD NUMBER
Special Medical Concerns, Allergies or Medications (FIFTH CHILD)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
PARENT Name*

First NameLast Name
EMERGENCY CONTACT INFO
EMERGENCY CONTACT NAME*

First NameLast Name
EMERGENCY CONTACT Phone Number*
Please enter a valid phone number.
COST $20 PER CHILD TO BE MADE BY
Etransfer: finance_ppt@hotmail.com Check payable to Pembroke Pentecostal Tabernacle
Parental Consent and Release Form

PPT KIDS CLUB REGISTRAION FORM 2024-2025 SEASON
PARENTAL CONSENT FORM
I, the undersigned First Name*Last Name* , am the parent or legal guardian of the child/children named above. As parent or legal guardian I give consent for my child/children named above to attend PPT KIDS CLUB at Pembroke Pentecostal Tabernacle, Pembroke Ontario, and any special PPT KIDS CLUB events which may take place off the church property. As a parent or legal guardian, I hereby voluntarily release, forever discharge the community, the corporation, its officers, directors, employees, volunteer and agents of Pembroke Pentecostal Tabernacle from any and all claims, demands, or causes of action, which are connected with my child's participation in the programs or the use of the equipment and facilities. I (We) The understand, in the event medial treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give permission to a licensed medical practitioner to provide the necessary care, including anesthesia, for my child's / children's well being. By signing this form on Date* , I confirm that I have fully informed myself of the contents of this Parental Consent and Release Form by reading it before I signed it. I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect. Signature*First Name*Last Name*
Do you give permission for your child to be photographed? (All photos are for 'in house' activities, promo or year end presentations)*
Should be Empty:

PPT KIDS CLUB REGISTRATION 2025-2026 SEASON

PLEASE NOTE: There is room to register 5 children. If you do not have 5 kids just skip past and fill out the information at the end and click on 'SUBMIT' or your form will not send.

EMERGENCY CONTACT INFO

Parental Consent and Release Form