Club Genesis Waiver

Bus Transport Registration
Child's Name

First NameLast Name
Gender
Child's Date of Birth

MonthDayYear
- Child's Name
  
  First NameLast Name
- Gender
- Child's Date of Birth
  
  MonthDayYear
  Date
- Child's Name
  
  First NameLast Name
- Gender
- Child's Date of Birth
  
  MonthDayYear
- Child's Name
  
  First NameLast Name
- Gender
- Child's Date of Birth
  
  MonthDayYear
  Date
- Child's Name
  
  First NameLast Name
- Gender
- Date of Birth
  
  MonthDayYear
- Parent/Legal Guardian's Name(s)
- Approved Contact(s) at Child's Residence(s)
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Alternate Pickup Address if Applicable
- Zip Code
- Primary Phone
  
  Area CodePhone Number
- We confirm if your child needs a ride each Thursday via text message. Please check the box to give us permission to text the primary phone listed.
- Secondary Cell
  
  Area CodePhone Number
- Pertinent Medical Information
- Additional Instructions
- Club Genesis/180/CWO Release & Waiver Form
- In consideration of the Child/Participant being permitted to participate in the Club Genesis/180 program, I/we do release, waive, forever discharge, and covenant not to sue Club Genesis/180/Cornerstone World Outreach, its governing board, officers, agents, employees, and/or any volunteers acting as employees, from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs and expenses of any nature which Child/Participant may have or which may hereafter accrue to Child/Participant, arising out of or related to any loss, damage, or injury, including but not limited to suffering and death, that may be sustained by the Child/Participant or by any property belonging to the Child/Participant and or the undersigned, property belonging to or in the care, custody, and/or control of the Child/Participant whether caused by the negligence or carelessness of the Releasees, or otherwise, while Child/Participant is in, on, upon, or in transit to or from the premises where the Activity or any adjunct to the Activity, occurs or is being conducted.
- Signature(s) of Parent(s) or Legal Guardian(s):
  
  *If using on a mobile phone, tilt phone horizontally to sign.
- Name
  
  First NameLast Name
- Today's Date
  
  MonthDayYear
  Date
- Should be Empty:

Bus Transport Registration

Club Genesis/180/CWO Release & Waiver Form