Kingdom KIDZ Registration Form

Medical Information
Allergies or Other Medical Conditions:*
Emergency Contact (other than the parent above)

In the case that we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent/guardian above).
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
Are there any other authorized people that can pick up your child/children*

YesNo
Name of Authorized Person & Relationship
Names of People who MAY NOT pick up your child/children from Awanas

This is to protect your child/children so that no one other than those listed above will be able to pick up your child/children from Awanas. Please be sure to communicate to your child/children that they are not able to go with this person(s).
Name of Authorized Person & Relationship

Photographic & Media Consent
You are being asked to give consent for the collection and use of your child’s personal images by photography or video recording.

If you give consent, you are acknowledging that these images may be used on the Ebenezer UB Church website as well as any video production that will be shown at the local church.

No personal information, such as names, will be used in any publications.
Media*

I HEREBY GIVE consent to the collection and use of my child’s personal images by photography or video recording.I DO NOT give consent for CEACT to collect and use my child’s personal images by photography or video recording.

Parental/Guardian Release Statement
I hereby consent to the participation of my child in all of Ebenezer UB Church Awanas supervised activities including Bible studies, indoor and outdoor recreational games, music, crafts, and snack times.

I, the Parent or Guardian named below, agree that if the child/children need any medical attention I authorize a representative of Ebenezer UB Church to contact myself and/or any of the authorized individuals listed in the order as given.

I, named below, undertake and agree to indemnify and hold blameless Ebenezer UB Church, its Personnel, its Leaders, and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the Awanas Program, as well as of any medical treatment authorized by the supervising individuals representing Ebenezer UB Church. This consent and authorization is effective only when participating in or traveling to events of Ebenzer UB Church Awanas Program.

I have read, understood and agree with above.
Name*
Signature*
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Kingdom Kidz Registration