Summer Park & Rec. Program Registration Form

The Summer Park and Rec Program will be here at Emmons Lutheran Church again. The mission of the program is to provide supervised and organized recreational activities for children in our community. The goals are to promote responsibility, respect, teamwork, and sportsmanship. These will help make the Summer Recreation Program a safe, positive, and productive experience for the children.

All activities will be at the south end of the church. We will begin on June 12th and ends on July 21st.

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian #1*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Number*

Home Number

E-mail*

example@example.com

Parent/Guardian #2

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Emergency Contact #1

Name*

First NameLast Name

Relationship*

Cell Phone Number*

Home Phone Number*

Email*

example@example.com

Emergency Contact #2

Name*

First NameLast Name

Relationship*

Cell Phone Number*

Home Phone Number*

Email*

example@example.com

Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Family Doctor Information

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Medical Insurance Information

Medical Insurance Company Name*

Phone Number*

Please enter a valid phone number.

Policy Number*

Group Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Emmons Summer Park & Rec. Program. In exchange for the participation of the said child, I release discharge, indemnify, hold harmless, and defend Emmons Summer Park & Rec. Program, its employees, assistants, and the Emmons Lutheran Church premises on which the program is conducted from any and all liability (claims, demands, losses, causes of action, suits, judgements) of any kind that I or my family may have against Emmons Summer Park & Rec. Program due to death, personal injury, or illness, loss or damage to property, or future causes that occur during the 2023 Emmons Summer Park & Rec. Program.

Initials*

Medical Release and Authorization

As the Parent and/or Guardian of the child, in the event of any medical emergency, I authorize and consent for Emmons Summer Park & Rec. Program to act on behalf for medical care deemed necessary for the participant.

In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the staff to contact you in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach the Parent and/or Guardian and the Emergency contacts listed above.

Permission is also granted to Emmons Summer Park & Rec. Program staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the life and limb of the named minor child, in my absence.

Initials*

Photo Release Agreement

I hereby give permission for my child to be photographed during the Emmons Summer Park & Rec. Program. I understand that I may revoke this authorization at any time by notifying the coordinator of the Emmons Summer Park & Rec Program in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports, and for promotional purposes including flyers, brochures, newspapers, and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Emmons Summer Park & Rec. Program.

Consent to child being in photographs? (If no, child's face will be blurred/excluded from pictures)

Initials*

Only the following person/s is allowed to pick up my child from Emmons Summer Park & Rec Program in the event that I am unable to:

First Person's Name

First NameLast Name

First Person's Phone Number

Please enter a valid phone number.

First Person's Relationship

Second Person's Name

First NameLast Name

Second Person's Phone Number

Please enter a valid phone number.

Second Person's Relationship

Third Person's Name

First NameLast Name

Third Person's Phone Number

Please enter a valid phone number.

Third Person's Relationship

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Registration & Information

Child's Information

Parent/Guardian Information

Emergency Information

Terms of Agreement