Emmaus Kidz & Company Membership Application

Name of Member:*

First NameMiddle NameLast Name

Email*

example@example.com

Child’s Home Phone #: *

Please enter a valid phone number.

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Church Affiliation:*

School Affiliation:*

Grade:*

Any known allergies:*

Medical Insurance: ?*

YesNo

Insured by:*

Insured by: #*

Note: For participants without medical insurance, please complete the Parental Release Form

Number of years Youth has participated in Emmaus Kidz?*

Does the member have siblings joining?*

YesNo

If yes, list names:

Choose T-Shirt or Polo Shirt and size

T-Shirts $10.00Polo Shirts $15.00

Size: Youth

SML

Size: Adult

Parent/Guardian:*

First NameLast Name

Parent/Guardian’s Home Phone #:*

Please enter a valid phone number.

Parent/Guardian’sCell #: *

Please enter a valid phone number.

Parent/Guardian’s Email:*

example@example.com

Emergency Contact: (Person to contact if parent/guardian is not available)*

First NameLast Name

Relationship to EK Member:*

Emer. Contact #:*

Please enter a valid phone number.

EK Member Signature:*

Parent/Guardian Signature: *

Date*

Date

I hereby grant permission and authorization for

Name of EK Traveler*

First NameLast Name

Age *

Birthdate*

Date

My child and/or myself (name listed above) to travel and participate in all activities with members of Emmaus Kidz of Mobile & Pensacola Mentoring Program. This authorization includes any regular meetings each as well as all special trips throughout the year.

I understand that the method of transportation will be Emmaus Kidz Bus/Vans for regular meetings-rehearsals and/or chartered buses or vans for special events which may include travel to various cities in the United States which I will be notified in advance. I also understand that pickup in Mobile and in Pensacola at Charity Chapel Church (Montgomery Avenue). Return destinations will be the same as pickup for each event.
As parent/guardian, it will be my responsibility to pick up my minor child after each activity/event and not the responsibility of Emmaus and its agents to transport my child home in Pensacola, Florida and/or Mobile, Alabama.

I assume all risks and liabilities which may result from my child participating and release and forever discharge and hold harmless Emmaus Road Outreach and Emmaus Kidz and its agents, servants, employees, and successors from any and all actions, causes of action, claims, demands and liabilities arising out of injury to or damage sustained by my child.

I agree to not hold the Emmaus Road Outreach and Emmaus Kidz against any and all liability or loss, and against all claims or actions based upon or arising out of damage or injury to persons or property caused by my child(ren).

In the event of injury to my child or myself, I hereby consent and authorize the administration of all treatments and tests that may be considered advisable or necessary in the judgment of any qualified medical personnel.

I understand that as a condition of my child or myself being a traveler, I will provide complete medical insurance coverage for any medical expenses which may be incurred. I agree to submit any medical bills incurred to my insurance company for payment. If my policy has been issued with a deductible clause relative to the personal injury protection, I understand that I have assumed that deductible amount when I purchased the policy. If I do not have medical insurance, I understand that all medical expenses will be my responsibility.

Parent/Guardian Signature (for travelers 0-17 years of age)*

First NameLast Name

Date*

Date

Traveler’s Signature (required for all travelers over 18)*

First NameLast Name

Date*

Date

Please verify that you are human*

Emmaus Kidz & Company Membership Application

The purchase of shirts not required at time of completing application.

EMMAUS KIDZ TRAVEL CONSENT FORM

Typing your name in the boxes below indicates your signature

Typing your name in the boxes below indicates your signature