Jesus Leadership Club Registration Form

Jesus Leadership Club

Participant Registration Form
Date*

MonthDayYear
Date
Child's Birthday*

MonthDayYear
Date
Child's Full Name*

First NameLast Name
Gender *
Current Grade *
Child's Current School
Child's Current School
School District of Child's School
Current School Sports/Clubs/Activities
Child's Address*

Child's Medical Information
Any Known Allergies*
Information helps to plan for snacks-if none type N/A
Medical Concerns/Special Needs*
Helps to accommodate child/ if not type n/a

Registering Parent/Guardian Information
Registering Parent/Guardian *

First NameLast Name
Relationship to Child*
Best Contact Phone Number *
Please enter a valid phone number.
Best Contact Email Address *
example@example.com
Registering Parent's/Guardian's Address *

Emergency Contact Information
Emergency Contact

First NameLast Name
Relationship to Child*
Emergency Contact Phone Number *
Please enter a valid phone number.

Participation Disclaimer/Media Release/Transportation Permission
PARTICIPATION CONSENT & DISCLAIMER

I hereby give consent for the child registered on this form to particpate in the Jesus Leadership Club (JLC) at Corinth Missionary Church located at 813 S. Cherokee Street, Social Circle, Georgia 30025.

I understand that JLC will teach Bible truths and Christian values through team building, leadership activities, stationary drills, and marching movements.

Although participation in the supervised practice of stationary drills and marching movements has minimal physical risk, serious injuries are uncommon in drill and ceremony practices and performances. It is possible only to minimize, not limit, the risk of minimal injuries. Participants have the responsibility to help reduce the chance of injury. PARTICIPANTS MUST OBEY ALL SAFETY RULES, REPORT ALL PHYSICAL PROBLEMS TO THEIR INSTRUCTORS, FOLLOW PROPER WARM-UP ROUTINES, AND FOLLOW ALL INSTRUCTIONS AT EACH MEETING.

By signing this permission form, you acknowledge that you have read and understand the above information.
MEDIA RELEASE

I consent for Corinth Missionary Baptist Church/Jesus Leadership Club to use the name, likeness, image, voice, and/or appearance of the child registered on this form in any pictures, video, recordings, audiotapes, digital images, and the like taken or made on behalf of Corinth Missionary Baptist Church/Jesus Leadership Club.

I agree that Corinth Missionary Baptist Church/Jesus Leadership Club. has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the mission of the Corinth Missionary Baptist Church/Jesus Leadership Club. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the website and social media pages. I acknowledge that said registered child will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Corinth Missionary Baptist Church/Jesus Leadership Club and its agents from and all claims which arise out of or are in any way connected with such use.
TRANSPORTAION WAIVER & RELEASE

I, the undersigned, give my consent for child registered on this form to be transported by Corinth Missionary Baptist Church/Jesus Leadership Club and will assume all liability for their participation in this work/activity/event and any injury that may happen in the duration of the transport or at the site of the work/activity/event.

Further, by signing below:

1)     I authorize Corinth Missionary Baptist Church/Jesus Leadership Club to procure and provide transport for my child/children.

2)     I will not hold Corinth Missionary Baptist Church/Jesus Leadership Club, its officers, clergy, agents, employees, members, volunteers, or anyone acting on its behalf responsible or liable for injury to the named person during such activities or the travel duration.

3)     I authorize Corinth Missionary Baptist Church/Jesus Leadership Club to transport and obtain any emergency medical care that may become reasonably necessary for the person during such work through a physician of their choice. /activities/events or the duration of travel and agree to accept the cost of the transportation and/or treatment by medical personnel or facility.

4)     I accept full responsibility and grant my minor child permission to travel with Corinth Missionary Baptist Church/Jesus Leadership Club
I have read and understand the following: *
I give consent for my child to participate in meetings and activities of Jesus Leadership Club at Corinth Missionary Baptist Church located at 813 S. Cherokee Road, Social Circle, GA 30025.

YesNo
I accept the terms of the Media Release for my child registered on this form.

YesNo
I accept the terms of Transportation Waiver & Release. If I check "no", I understand my child will not be transported by leaders of the Jesus Leadership Club or Corinth Missionary Baptist Church to activities or meetings unless I sign a permission granting my consent.

YesNo
Signature

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