Bethany Kids Registration Form
Please complete the registration details for your child(ren). All fields are optional unless clearly required in the source.
Parent / Guardian Information
Parent/Guardian Name
First Name
Middle Name
Last Name
Parent/Guardian Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Name
First Name
Middle Name
Last Name
Parent/Guardian Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
City
State
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Name(s) of others authorized to pick up child(ren)
Email
example@example.com
Where will you usually be located while your children are at Bethany Kids church event/service?
Child 1 Information
Child 1 Full Name
First Name
Middle Name
Last Name
Child 1 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 1 Age
Child 1 Grade
Child 1 Gender
Please Select
M
F
Child 1 Known Allergies or Medical Condition
Child 2 Information
Child 2 Full Name
First Name
Middle Name
Last Name
Child 2 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 2 Age
Child 2 Grade
Child 2 Gender
Please Select
M
F
Child 2 Known Allergies or Medical Condition
Child 3 Information
Child 3 Full Name
First Name
Middle Name
Last Name
Child 3 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 3 Age
Child 3 Grade
Child 3 Gender
Please Select
M
F
Child 3 Known Allergies or Medical Conditions
Child 4 Information
Child 4 Full Name
First Name
Middle Name
Last Name
Child 4 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 4 Age
Child 4 Grade
Child 4 Gender
Please Select
M
F
Child 4 Known Allergies or Medical Conditions
Program Selection and Consent
Bethany Kids Programs
*
ALL
Nursery
Sunday School
Sunday AM Morning Worship Class
AWANA
RELEASE OF LIABILITY, PHOTO RELEASE AND CONSENT OT MEDICAL TREATMENT 1. RELEASE OF LIABILITY: I, for myself, my minor child and for the child’s other parent and/or guardian, hereby release, waive, discharge, and covenant not to sue Bethany Baptist Church, New Brockton, AL, and its officers, director, employees, agents, volunteers, heirs and assigns of and from all liability, loss, claims, demands, possible causes of action, court costs, attorney’s fees and other expenses arising from any lawsuit that might otherwise occur from any loss, damage or injury to my child’s person or property in any way resulting from or connected with my child’s attendance at Awana, including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons. 2. PHOTO RELEASE: I give permission for my child to appear in a photo or video, which may be taken during Awana to appear on Bethany Baptist Church Facebook Page or website or be use for publicity or display purposes. Note: no private information will be disclosed publicly. 3. CONSENT TO MEDICAL TREATMENT: In the event my child becomes ill or injured, I give permissions for a representative of Bethany Baptist Church to take whatever steps are reasonably necessary to render emergency first aid to my child. I also consent to such emergency medical treatment as may be the health and welfare of my child including, but not limited to, x-rays, anesthetic, medical or surgical diagnosis and treatment, hospital care and administrations of drugs or medicine under the care of a licensed physician and/or surgeon.
I have read and agree to the Release of Liability
I have read and agree to the Release of Liability
*
Yes
I give permission for Photo Release
*
Yes
No
I give Consent to Medical Treatment
*
Yes
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Zip
Submit
Submit
Should be Empty: