• The Church in Anaheim — Children and Young People Family — REGISTRATION FORM

    One Form for every family

  • Parent/Guardian 1

  • Parent/Guardian 2

  • Emergency Contact Person

    If the above person(s) cannot be reached in the event of an emergency or disaster, serving ones may contact and/or release child to:

  • Individual Child's Information

  • Child 1

  •  - -

  • Insurance/Care Provider:
    Group/Medical:
    Physician:         
    Phone:    

  • Child 2

  •  - -

  • Insurance/Care Provider:
    Group/Medical:
    Physician:         
    Phone:    

  • Child 3

  •  - -

  • Insurance/Care Provider:
    Group/Medical:
    Physician:         
    Phone:    

  • Child 4

  •  - -

  • Insurance/Care Provider:
    Group/Medical:
    Physician:         
    Phone:    

  • Child 5

  •  - -

  • Insurance/Care Provider:
    Group/Medical:
    Physician:         
    Phone:    

  • I, * * hereby authorize the responsible adult serving ones in the local church in which my child(ren) and I are members who are accompanying and chaperoning my child(ren) at the church-sponsored or church-organized home, conference, event or activity in which my child(ren) are attending or participating in, to call an emergency ambulance or seek any medical care that they deem necessary in case of accident, injury or other emergency at their best discretion if I am not immediately available. I understand that every effort will be made to contact me before, during and after the emergency. I agree to HOLD HARMLESS AND INDEMNIFY the local church in which I am a member, and any of the other affiliated local churches or church- affiliated organizations, members, serving ones, responsible adults, or volunteers present at the homes, conferences, events or activities referenced above, from any and all injuries, claims, damages, liability, costs and expenses including, but not limited to, attorneys' fees, litigation expenses, court costs, and all other sums which the persons and organizations referenced above may pay or become obligated to pay on account of any, all and every demand for claim or assertion of liability, or any claim or action founded thereon, arising or alleged to have arisen out of the church- sponsored, church-organized, or church activities referenced above involving my children.

  • Clear
  •  - -
  • Should be Empty: