BreakOut Registration

BreakOut Registration

2026/2027
Student Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age as of December 31, 2026
Grade
School
Parent/Guardian Name(s)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies or Medical Conditions
Medical Care Card Number
Doctor's Name
Emergency Contact (only contacted if parent can't be reached)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I give consent to have my child's pictures used by the church for church related use such as brochures, website, Facebook, etc.

Liability Release

Please read carefully read the following information and consent form.
While every precaution is taken for the safety and good health of your child, some activities, including transportation, carry with them the inherent risk of personal injusry. Your permission is required to provide this transportation. If you are in agreement, please sign below.

I, the parent or guardian of the above named, give my permision for my child to participate in BreakOut activities, both in the church building and including trips away from the church premises. I also give persmision for my child to ride in any vehicle driven by an approved adult chaperone while attending the BreakOut activities. I understand that SEAT BELTS WILL BE WORN AT ALL TIMES during transportation. I authorize the Director or sponsors of North Peace MB Church to sign consent for medical treatment and to authorize any physician or hospital to provide medical assistance, treatment or procedures for the participant named aboce. I undertake and agree to indemnify and hold blameless North Peace MB Church, its personnel, volunteers, directors and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the group, as well as of any medical treatment authorized by the supervising individuals representing North Peace MB Church. This consent and authorization are effective only when participating in or traveling to events of the North Peace MB Church.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

Student Commitment

Please go over with your child
During BreakOut activities, I realize that I am responsible for my actions. I will:

- Respect the leaders and other students in the BreakOut group.

- Respect the things I use and the property of places I visit.

- Respect the drivers and keep my seat belt on while traveling.

- Stay within the group and not wander off without letting a leader know.

If I choose to break these rules during a BreakOut event, I am giving permision for my parent/guardian to be called to pick me up and take me home.

In signing this, I agree to the guidlines listed above
Signature of student
Signature of parent/guardian
Should be Empty:

BreakOut Registration

Liability Release

Student Commitment