MCKids Registration Form – PLEASE COMPLETE

MCKids Registration Form – PLEASE COMPLETE

This form accommodates registration for up to three children. For families with more than three children, please submit an additional form to ensure all children are included. For any questions, please email mc2@mcfgc.org
Today’s Date*

MonthDayYear
Date
Tiny Town (6wks to 3yrs)Primary (4yrs to 7yrs)Kidz & Teenz (8yrs - 18 yrs)
Parent/Legal Guardian or Responsible Person Information:
Full Name of Person Registering Child/Teen:*
SelfMotherFatherOther
Other Relationship (please specify)
Check Check here if you (adult) are also visiting Mt. Canaan Full Gospel Church for the first time.
Birthdate (mo/day/year)

MonthDayYear
Date
Best Contact Phone Number(s)*
Cell/Home
Email Address
example@example.com
Address

Address

Street Address Line 2

City/StateState / Province

Zip
*Emergency Contact Phone Number*
Format: (000) 000-0000.
Emergency Contact Name*
If you are not the parent or guardian and this information wasn’t provided in the previous section, please complete the below.
Mother's /Guardian's Name:
Birthdate

MonthDayYear
Date
Address

Street Address

CityState / Province

Postal / Zip Code
Best Contact Phone Number
Best Contact Phone Number #2
Email
example@example.com
Father's /Guardian's Name:
Birthdate

MonthDayYear
Date
Address

Street Address

CityState / Province

Postal / Zip Code
Best Contact Phone Number
Best Contact Phone Number #2
Email
example@example.com
Emergency Contact Name/ Relationship to child:
Best Contact Phone Number
Best Contact Phone Number #2
CHILD/TEEN INFORMATION:
1.Child/Teen’s Full Name*
MaleFemale
Child#1 Age*
Child#1 Grade*
Enter Child's Age if not applicable.
Child#1 Birthday (mo/day/yr)*

MonthDayYear
Date
Child#1 Allergies/Health Concerns/Notes: ex.: glasses, hearing aid, asthma, insect or food allergies, special feeding instructions, etc*
Enter 'None' or 'N/A' if not applicable.
2.Child/Teen’s Full Name
MaleFemale
Child#2 Age
Child#2 Grade
Enter Child's Age if not applicable.
Child#2 Birthday

MonthDayYear
Date
Child#2 Allergies/Health Concerns/Notes: ex.: glasses, hearing aid, asthma, insect or food allergies, special feeding instructions, etc*
Enter 'None' or 'N/A' if not applicable.
3.Child/Teen’s Full Name
MaleFemale
Child#3 Age
Child#3 Grade
Enter Child's Age if not applicable.
Child#3 Birthday

MonthDayYear
Date
Child#3 Allergies/Health Concerns/Notes: ex.: glasses, hearing aid, asthma, insect or food allergies, special feeding instructions, etc*
Enter 'None' or 'N/A' if not applicable.
Liability/Medical/Media Release (Initial Each Section and Sign)
Activities: I authorize Minor(s) to attend and participate in activities offered by Mt. Canaan Full Gospel Church, its representatives, and employees. I agree, individually and on the behalf of Minor(s), to release and to hold MCFGC/MCKIDS harmless from any liability or claims resulting from his/her participation in MCFGC/MCKIDS activities. *
Initial
Injuries: In the event that Minor(s) are injured during the MCFGC/MCKIDS activities, and I am unable to provide consent to his/her medical treatment, I authorize a MCFGC/ MCKIDS representative to consent on my behalf to the performance of any and all medical treatment judged necessary by MCFGC/MCKIDS or authorized medical personnel. I agree, individually and on behalf of Minor(s), to release and hold MCFGC/MCKIDS harmless from and against any liability, which may be assessed against MCFGC/MCKIDS as a result of said medical treatment.I agree to pay or arrange for payment for all cost associated with said medical treatment.*
Initial
Photos/Videos: I grant MCFGC/MCKIDS, its representatives, and employees the right and permission to publish, distribute and/or use photographs/video/audio of any member of my family in the MCFGC/MCKIDS and/or ministry environment. I authorize such productions for use in its own media productions, through commercial media and/or online media, in print and/or electronically with or without names for any lawful purpose or advertisement.*
Initial
By signing below, I acknowledge that I have read and understand the foregoing statement of release, and I affirm that the information provided herein is true, accurate, and complete to the best of my knowledge and belief.
Responsible Person’s Name
Responsible Person’s Signature*

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Date*

MonthDayYear
Date
Should be Empty:

MCKids Registration Form – PLEASE COMPLETE

Parent/Legal Guardian or Responsible Person Information:

If you are not the parent or guardian and this information wasn’t provided in the previous section, please complete the below.

CHILD/TEEN INFORMATION:

Liability/Medical/Media Release (Initial Each Section and Sign)