Kids Club Registration Form/Wavier

Kids Club Registration/Waiver Form
Student Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
Gender:
Parent/Guardian:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Alternate Emergency Contact:

First NameLast Name
Relationship to child:
Phone Number:
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Food Allergies

YesNo
If yes, please list:
Medical Concerns

YesNo
If yes, please list:
Will you require van transportation?

YesNo
I, Your name ,as parent/legal guardian of, Child's name, do hereby give my child permission to attend Kids Club. In consideration of the privilege of allowing my child to participate in above-named activity, I agree to release and hold harmless Mt. Zion Missionary Baptist Church, or any of its members, from any liability to or responsibility for bodily injury, damage or illness to the above-identified child while participating in child athletic, social activity, or transportation to and from the church if provided by the church which may be directly or indirectly sponsored by the Church. Further, I agree to indemnify and hold harmless the Church, or any of its members with respect to any claim asserted by or on behalf of my child as a result of bodily injury, illness, or damage.
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Date

MonthDayYear
Date
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Kids Club Registration/Waiver Form