2025 Annual Gathering Childcare Registration

2025 ABCCR Annual Gathering Childcare Registration Form

September 26-27, 2025 Annual Gathering

First Baptist Church of Salina, 843 Lewis Ave. Salina, KS 67401

Please complete a separate registration form for each person

Child's First and Last Name*

Print your name as you want it to appear on your name tag

Child's Age*

Child's Grade*

Address*

Address

Street Address Line 2

City

Zip

Church Name*

City*

Parent/ Guardian First and Last Name*

Phone*

Email*

example@example.com

Emergency Contact First and Last Name*

Emergency Contact Phone*

Relationship to Child*

Childcare Registration

Childcare for Friday– $50

Friday childcare will be provided from 8:00 AM- 5:30 PM, lunch and dinner are included in the cost of childcare. Childcare will not be provided during dinner or the evening session.

Childcare for Saturday– $12

Saturday childcare will be provided from 8:00 AM- 12:00 PM, no meals are provided.

Choose Your Childcare

Childcare for Friday– $50Childcare for Saturday– $12

I will be paying by:

Credit CardCheck (Mail Check to ABCCR: 5889 SW 29th St, Topeka, KS 66614)

Medcial and Image Release

Consent for Emergency Medical Care for a Minor: By signing this form, I hereby authorize the Kansas Baptist Convention, Inc. also known as the American Baptist Churches of the Central Region and First Baptist Church of Salina, Ks to consent to any medical care and treatment for my child that is recommended by a licensed healthcare provider to whom the Child is presented for treatment. To ensure that the Child receives prompt medical care and treatment, when necessary, I hereby release any licensed health care provider providing medical care to the Child
in reliance of this form from liability relating to such provider's acceptance of my substitute caregiver's consent.

If you consent, sign your name here:*

I, the undersigned individual, grant American Baptist Churches of the Central Region (ABCCR located at 5889 SW 29th St, Topeka, Kansas, and First Baptist Church of Salina, KS the perpetual, non-exclusive, royalty-free right and license to:

Record my/ my child's participation and appearance on digital or film photography, video, audio or any other medium. Use my name (or any fictional name), likeness, voice, and biographical material and information in connection with these recordings to be used only in or for ABCCR written, electronic and web publications, including social media and apps to be used for the promotional material, multimedia and publication purposes of the American Baptist Churches of the Central Region.

To Reproduce, distribute, publicly display, and/or publicly perform, in print, electronic, or any other medium, copies of the recordings, in whole or in part. Grantor represents that he or she possesses all rights necessary to grant this permission for and in connection. I am voluntarily making this grant of rights. I further agree to release and forever discharge ABCCR, its agents, employees, and designated representatives from any and all claims in law or equity that I, my heirs, or personal representatives have or shall have arising out of recordings. I am the parent or guardian of the minor named above and have the legal authority to execute the above release. I approve and waive any rights in this release.

If you consent, sign your name here:*

Registration Total

USDAnnual Gathering 2025

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country