CAC Sibshops Registration

Sibshops Registration

Please fill out the form carefully to register your child for Sibshops at the JAFCO Children's Ability Center.
Child Name

First NameLast Name
Birth Date

MonthDayYear
Age
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian Name

First NameLast Name
Parent/Legal Guardian E-mail
example@example.com
Parent/Legal Guardian Phone Number
Format: (000) 000-0000.
Does your child have any allergies or dietary restrictions? If yes, please list them below.
Is there anything else you'd like us to know about your child?

SERVICES AND EMERGENCY CARE RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT
Person Served: {personServed}
By signing below, I, on behalf of myself, the above-named minor child or person served and our respective heirs, assigns and personal representatives, agree to release, hold harmless and indemnify JAFCO Children’s Ability Center, Inc., including its employees, staff, agents and officers (JAFCO), from or for any and all liability, claims, losses, demands, expenses, and causes of action whatsoever for personal injury or property damage/loss of any kind resulting from or arising out of JAFCO’s services, any emergency care or transport provided to the above-named minor child, or the above-named minor child’s presence on or about JAFCO’s premises, except to the extent any such injury, damage or loss is caused by the gross negligence of JAFCO.
Please read and check the box below:
Parent/Legal Guardian Name

{parent}
Parent/Legal Guardian Signature
Date

MonthDayYear
Date
Person Served Name

{personServed}
Person Served Signature
Date

MonthDayYear
Date

EMERGENCY CONTACT INFORMATION
Person Served: {personServed}
Emergency Contact

This should be someone other than the parent/legal guardian that you listed on the first page of this registration form.
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship to Person Served
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

PERMISSION TO PHOTOGRAPH OR VIDEOTAPE
Person Served: {personServed}
I hereby give permission for my child {personServed}, born on {birthDate}, to be photographed or videotaped and for the photograph(s) or video(s) to be used to raise awareness and/or funds to further the mission of the JAFCO. Additionally, I understand that these images and videos may be shared on JAFCO's social media accounts to expand community outreach efforts.
This permission may be withdrawn verbally or in writing at any time and is valid:
Parent/Legal Guardian Name

{parent}
Parent/Legal Guardian Signature
Date

MonthDayYear
Date
Person Served Name

{personServed}
Person Served Signature
Date

MonthDayYear
Date
Should be Empty:

Sibshops Registration