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)*
If your child attends Jack Kemp Community School do you want them to be transported by van to the club while under the supervision of Living Faith Church volunteers?*

YesNo
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.*
If your child will NOT be collected by you or a designated adult, family member or friend do you give permission for him/her to leave the church premises unaccompanied when Kids Zone or 56'ers dismisses?*

YesNo
Are you able to help on occasion in any of the following ways: (check all that apply)*

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
Do you authorize Living Faith Church to use photographs or videos of your child, taken for the purpose of non-profit publications? (check all that apply)*

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