Heavenly Culture Kids 2026 Registration and Waiver

Heavenly Culture Kids 2026 Registration and Waiver

Complete the registration, waiver, consent, emergency, medical, pickup authorization, and signature details for Heavenly Culture Kids . Preserve the document’s structure and include all waiver/consent text.
Event and Child Information
Event Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child’s Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Parent/Guardian and Household Information
Parent/Guardian Name

First NameMiddle NameLast Name
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How many children from your family will attend?
Names of additional children attending
Will a parent/guardian remain on site?
Emergency Contacts and Medical Information
Emergency Contact #1 Name

First NameLast Name
Emergency Contact #1 Relationship
Emergency Contact #1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Relationship
Emergency Contact #2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Allergies
Medical conditions / relevant health information
Medications that may affect participation
Dietary restrictions
Special accommodations, sensory needs, mobility needs, or other information staff should know
Authorized Pick-Up and Permission
Authorized Pick-Up 1 Name

First NameMiddle NameLast Name
Authorized Pick-Up 1 Relationship
Authorized Pick-Up 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up 2 Name

First NameMiddle NameLast Name
Authorized Pick-Up 2 Relationship
Authorized Pick-Up 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up 3 Name

First NameMiddle NameLast Name
Authorized Pick-Up 3 Relationship
Authorized Pick-Up 3 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Photo / Video Permission
Waiver Acknowledgment, Signatures, and Internal Tracking
Waiver and consent acknowledgment

1. PARTICIPATION, ASSUMPTION OF RISK & RELEASE
I understand that participation in a children’s church/VBS program may involve ordinary risks associated with group activities, games, crafts, movement, food, use of facilities and equipment, and interaction with other participants. I voluntarily allow my child to participate and acknowledge these risks.

To the fullest extent permitted by applicable California law, I agree to release and hold harmless the church and the program’s directors, officers, employees, and volunteers from claims arising from my child’s voluntary participation in the program, except to the extent a claim cannot legally be released. Nothing in this form is intended to waive or release liability that California law does not permit to be waived or released, including liability for fraud, willful injury, violation of law, or other non-waivable conduct.

I understand that this release is not a guarantee that the church is free from all legal responsibility and that I have had an opportunity to ask questions before signing. I understand that the church does not provide health or accident insurance for my child unless separately stated in writing.

2. PROGRAM EXPECTATIONS
I understand that the program may ask a child to follow reasonable safety instructions, remain with their group, and treat leaders and other children respectfully. I understand that the church may contact me to pick up my child if behavior, illness, or another circumstance makes continued participation unsafe or inappropriate.

3. PHOTO / VIDEO PERMISSION
Please select one: ☐ YES, I give permission for my child’s image/video to be used for church/ministry communications (website, social media, slides, promotional materials). ☐ NO, please do not use my child’s image/video.

I understand that choosing NO will not prevent my child from participating.

4. PARENT/GUARDIAN ACKNOWLEDGMENT
By signing below, I confirm that I am the child’s parent or legal guardian, that the information provided is accurate to the best of my knowledge, and that I have read and understand this registration, medical authorization, participation release, and photo/video selection.
Parent/Guardian Printed Name

First NameMiddle NameLast Name
Parent/Guardian Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Registration Received Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Heavenly Culture Kids 2026 Registration and Waiver

Event and Child Information

Parent/Guardian and Household Information

Emergency Contacts and Medical Information

Authorized Pick-Up and Permission

Waiver Acknowledgment, Signatures, and Internal Tracking