Oak Creek Registration and Liability Waiver

Oak Creek Wednesday Night

833 Lincolnway East Mishawaka, Indiana 46544 Wednesdays 6:30pm to 8:00pm during school year
Youth Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Grade Level
Does the child have any allergies or medical concerns?
Any Other Information We May Need:(Behavioral concerns, custody notes, dietary restrictions, etc.)
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship
Photo/Video Consent

Photos and videos are only taken by designated leaders, under the guidelines of our child safety policy, and are only used for church marketing purposes.
Photo/Video Consent
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
- Parent/Guardian registered in this form has legal custody over the child.
- I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult volunteer driving.
- For medical emergencies, I allow the medical team of this organization to take care of my child.
- I release this organization from any and all liability from accident or injury to the child during the organization related events.
Parent/Guardian Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Oak Creek Wednesday Night