Friday Afternoon Builders
Kimball Trinity United Methodist Church
Child Registration
Child's Name
*
First Name
Last Name
Birthdate
*
/
Month
/
Day
Year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parents/Guardians
Parents/Guardians
*
Emergency Contacts
in addition to the parents/guardians
Emergency Contacts
*
Child Pick Up
other people who have permission to pick up child
Authorized to Pick Up Child
Health Release
I give permission for the FAB staff to act on my behalf, to take measures they deem necessary in the event of an emergency, sickness, or injury during the program. I agree to pay for any medical expenses for my child whose name appears above.
*
Yes
No
Current Medical Conditions
*
please include food allergies & medications
Permissions
Photography: I give permission to the program to take and use photographs and video of my child for the purpose of promoting the program. (ex: On our website, in program brochures, etc)
*
Yes
No
Transportation: I give permission for the program to provide transportation to and from the program.
*
Yes
No
Walk Home: My child has permission to walk home from the program.
*
Yes
No
Liability Release
Release of Liability
*
I hereby grant permission for this child to be transported to an emergency medical or healthcare facility for immediate treatment and/or consultation if deemed necessary. I understand that this child's emergency contact will be notified of any emergency situation immediately. I agree to be financially responsible for any and all medical expenses and/or treatment costs, and I release the Kimball Trinity United Methodist Church and all associated volunteers or staff from any liability.
I accept full responsibility for any legal or financial consequences, i.e., damage to property or other participants/staff, that may result from any personal actions taken by me or this child, and I agree to hold the Kimball Trinity United Methodist Church and all associated volunteers or staff harmless with respect to any actions or claims that may be made in connection with personal actions taken by me or this child.
Parent/Guardian eSignature
*
This serves as my eSignature and indicates that all information entered above is accurate and true.
eSignature Date
*
/
Month
/
Day
Year
Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: