Back to school bash student registration
Child information
Child’s Name
*
First Name
Last Name
Nickname
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age of child
*
Grade level
*
Gender
*
Male
Female
Food allergies
*
Other special needs/ medical concerns
*
Parent / guardian information
Name
*
First Name
Last Name
Contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact
If parent / guardian cannot be reached
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship to the child
*
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Parental consent & authorization
1. I grant Poarch Community Church permission to photograph and/or video record my child during BTSB for use on the church website, social media, and printed materials. My child's full name will not be published without additional consent.
*
I give consent to my child getting photos/ videos taken
*
Yes
No
2. In the event of illness or injury, I authorize BTSB staff to administer basic first aid, contact emergency services (911), and transport my child to the nearest medical facility if I or my emergency contact cannot be reached. I accept financial responsibility for any medical expenses incurred.
*
3. My child may ONLY be released to the persons listed below. A valid photo ID may be required.
*
Authorized pickup person #1
*
First Name
Last Name
Authorized pickup person #2
*
First Name
Last Name
Relationship of child Authorized pickup person #1
*
Relationship to child Authorized pickup person #2
*
Phone Number of Authorized pickup person #1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number of Authorized pickup person #2
*
Please enter a valid phone number.
Format: (000) 000-0000.
4. I acknowledge that BTSB includes physical activities (outdoor games, crafts, water play with inherent risks of minor injury!)voluntarily assume these risks and release Poarch Community Church, its staff, and volunteers from liability arising from my child's participation, except in cases of gross negligence.
*
5. I understand snacks will be provided during BTSB. I have listed all food allergies on the registration form. While the church will make reasonable efforts, they cannot guarantee an allergen-free environment.
*
I understand snacks may be provided during BTSB . I have listed all food allergies on the registration form. While the church will make reasonable efforts, they cannot guarantee an allergen-free environment.
*
My child MAY receive snacks provided by BTSB
My child MAY NOT receive snacks. I will provide my own.
Acknowledgment & signature
By signing below, I confirm that I have read and agree to all sections above (1-5). All information on this form is accurate and complete. I understand that incomplete forms may affect my child's participation.
*
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