Back to Madison Street Family Registration Form

1
Primary Adult Full Name* This field is required.
First Name
Middle Name
Last Name
2
Email Address* This field is required.
example@example.com
3
Mobile Phone Number* This field is required.
Please enter a valid phone number.
4
Number of Adults Attending* This field is required.
5
Number of Children Attending* This field is required.
6
Is this your first time attending Madison Street UMC?
Yes
No
7
Are you new to Clarksville?
Yes
No
8
How did you hear about the event?
Please Select
Please Select
Church announcement
Friend or family
Social media
Flyer or poster
Website
Other
9
Will your household be bringing any children?* This field is required.
Yes
No
10
Child details* This field is required.
11
Emergency Contact Name* This field is required.
First Name
Middle Name
Last Name
12
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
13
Emergency Contact Relationship to Child* This field is required.
Please Select
Please Select
Parent
Guardian
Grandparent
Aunt/Uncle
Sibling
Family Friend
Other
14
Adult Responsible for Supervising the Children* This field is required.
First Name
Middle Name
Last Name
15
Acknowledgment: This is not a drop-off event. A parent, guardian, or responsible adult must remain on site with the children.* This field is required.
16
Relationship to the child* This field is required.
Please Select
Please Select
Parent
Legal guardian
Grandparent
Foster parent
Other
17
I acknowledge and understand the risks of inflatable activities* This field is required.
I understand that inflatable activities involve risks, including falls, collisions, and other injuries
I agree that the child will follow all posted rules and staff instructions
I confirm the child is physically able to participate
I authorize emergency assistance to be provided if needed
18
I acknowledge the bounce-house safety rules* This field is required.
Children must follow the attendant’s instructions
Shoes, food, drinks, jewelry, and sharp objects are not allowed
No pushing, wrestling, flips, or climbing on the inflatable walls
Children may be separated by age or size
Children who are sick or injured may not participate
The supervising adult remains responsible for the child
19
SignatureI certify that I am the parent or legal guardian of the child or children listed on this registration and have the legal authority to give permission for their participation. I voluntarily give permission for my child or children to participate in bounce houses, inflatable slides, inflatable obstacle courses, and other inflatable activities offered during Back to Madison Street at Madison Street United Methodist Church. I understand that inflatable activities involve risks that cannot be completely eliminated, including slipping, falling, loss of balance, collisions with other participants, contact with the inflatable or surrounding objects, strains, sprains, bruises, broken bones, head or dental injuries, and other serious injuries. I understand that injuries may result from my child’s actions, the actions of other participants, failure to follow instructions, equipment movement, weather conditions, or other expected or unexpected circumstances. I confirm that my child is physically and medically able to participate. I will not allow my child to participate while sick, injured, or experiencing a condition that could be worsened by jumping, climbing, running, falling, or physical contact. I have provided accurate information about any medical conditions, allergies, physical limitations, or accessibility needs that could affect participation. I understand that Back to Madison Street is not a drop-off event. I agree that a parent, guardian, or responsible adult will remain at the event and supervise my child. My child must follow all posted rules and all instructions provided by church staff, volunteers, and inflatable attendants. I understand that children may be separated according to age, height, weight, size, or ability. My child agrees not to engage in pushing, wrestling, flips, rough play, climbing on inflatable walls, or intentionally colliding with others. Shoes, food, drinks, gum, jewelry, sharp objects, toys, and loose items are not permitted inside the inflatables. Madison Street United Methodist Church or the inflatable operator may deny or end participation when necessary for safety. If I cannot be reached during an emergency, I authorize Madison Street United Methodist Church staff, volunteers, and event representatives to provide reasonable first aid, contact emergency medical services, and arrange emergency transportation when they reasonably believe it is necessary. I understand that I remain financially responsible for any medical care or transportation provided to my child. To the fullest extent permitted by Tennessee law, I release Madison Street United Methodist Church, its trustees, clergy, employees, members, volunteers, representatives, and agents from claims belonging personally to me that arise from my child’s participation in the inflatable activities. This release does not waive any independent legal claim belonging to my child or any claim that cannot legally be waived.
20
May Madison Street UMC photograph or record members of your household during the event?
Yes
No
Should be Empty: