Kids Zone & 56'ers Registration

Kids Zone & 56'ers Registration - Tuesday Club

Living Faith
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
School & Grade*
Parent's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency contact name & number (if different from above)*
Child's health conditions and/or allergies (if any)*
Child's medication and/or prescription drugs (if any)*
Health Care Number*
Primary Care Physician's Name*

First NameLast Name
Physician's Telephone Number*
Please enter a valid phone number.
Siblings attending Kids Zone or 56'ers (names/ages)*
Jack Kemp Community SchoolRendell Park Community SchoolNo
Will your child be collected from Kids Zone or 56'ers by a designated adult, family member or friend other than you? If so, please provide their name(s) and telephone number(s) below.*
YesNo
Food for Special OccasionsPreparation for Special Occasions (decor, set-up, etc)Fill-in for a volunteer who is unexpectedly awayUnable to help at this time
Printed PublicationsAudio Visual MediaWeb PublicationsNo to all
AUTHORIZATION AND CONSENT OF PARENT or LEGAL GUARDIAN

As custodian of the aforementioned minor, I grant my authorization and consent for a designated adult to administer general first aid treatment for minor injuries or illnesses. If the injury or illness is severe, I authorize him or her to seek professional emergency personnel to attend, transport, and treat the minor and to issue consent for any medical care deemed advisable by a licensed medical professional or institution. I authorize the designated adult to exercise best judgment upon the advice of medical or emergency personnel.
Todays Date*

MonthDayYear
Date
Signature*

Clear
Parent/Guardian Name:*

First NameLast Name
Should be Empty:

Kids Zone & 56'ers Registration - Tuesday Club