PEAK Registration Buckys Bay 2008

Child's Name:
Child's Age
Child's Gender
Mother's Name
Father's Name
- Email Address
- Home Phone:
- Mother's Work #
- Father's Work #
- Address:
- City:
- State:
- Zip code:
- Other Emergency Contact
- Other Emergency #
- Family Physician
- Phone
- Medical Health #
- Medication Presently Being Taken
- Does the child have any ailments that the coach of staff should be aware of (ie: allergies, athletic injuries, etc.)
- I hereby grant my child permission to participate in the Peak Experience Program, and if I cannot be readily contacted I authorize the BranchCreek Community Church to provide or cause to be provided such medical services as the church or medical personnel consider appropriate. Peak Experience reserves the right to refuse further participation to any participant for inappropriate behavior. By signing this consent, I agree to allow BranchCreek Community Church to reproduce the likeness of my child (photo, video, etc.) in promotional materials or publications.
- I am aware that participation in recreation and athletic activity involves the risk of personal injury including but not limited to soft tissue and/or broken bones. Any use of equipment facilities and programs of the BranchCreek Community Church, and my or my child's participating in such activities shall constitute acceptance of the risk regardless of the nature of the injury.
- I Grant Permission
- You must complete Checkout process to be registered - Thank You
- Should be Empty: