Equip Kids Club Registration Form

Equip Kids Club Registration Form

Fill out the form carefully for registration
Parents/Grandparent/Caregiver Name *

First NameMiddle NameLast Name
Child #1*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Grade*
Medical #*
Allergies, medical concerns, behavioural concerns that affect your child and/or the children around them:*
If none Type NA
Child #2

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Grade
Medical #
Allergies, medical concerns, behavioural concerns that affect your child and/or the children around them:
If none Type NA
Child #3

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Grade
Medical #
Allergies, medical concerns, behavioural concerns that affect your child and/or the children around them:
If none Type NA
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number*
Phone Number
Work Number
Emergency Contact Name: (other than parents) *

First NameMiddle NameLast Name
Relationship to child*
Mobile/Home Number*
- I hereby authorize North Kildonan Mennonite Brethren Church (NKMB) to provide supervision and care for all children registered above. - My children will follow all regulations as set out by Manitoba Public Health - I consent to use of photographs and video of my child by NKMB - I understand that reasonable safety precautions will be taken - I understand that medical treatment will be administered in case of emergency and that all efforts will be made to contact me - I understand that my child has voluntarily chosen to participate in all activities including but not limited to, singing, bible stories, indoor and outdoor sports activities (including bouncers), crafts and snacks - I understand that my child will be asked to discontinue participating should he/she disregard expected behaviour guidelines, any and all necessary transportation arrangements will be my responsibility. *
By selecting agree you are signing that you agree with the above statements
Date*

MonthDayYear
Additional Comments
Should be Empty: