Children & Youth Registration/Medical Release Form

Registration Date *

MM

DD

YYYY

First Friday Only

Yes

Name of Participant *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Parent(s)/Guardian(s) Name *

First Name

Last Name

Phone *

(###)

###

####

Alternative Emergency Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Photo Release *

I hereby give permission for the Little River United Church of Christ (LRUCC) to use the photographic image of my child in any of their publications, including, but not limited to, the LRUCC Website, brochures and newsletters. This permission extends to all photographic images in which it was intended that my child recognizably appear, subject to any limitation listed at the bottom of this form.

Yes

No

Additionally *

I understand that I may rescind this permission at any time, and that upon notification, LRUCC will take all reasonable precautions not to continue to use my child’s photographic image in any future publications unless expressly authorized by me. I understand that it is the intent of LRUCC to use any and all photographic images of my child for the sole purposes of LRUCC activities.

Yes

No

Please initial one of the following: *

After class, my child is to wait in the classroom for a parent/guardian to arrive.

After class, my child has my permission to be dismissed from class without supervision.

Parent/Guardian Permission and Release of Liability *

I give permission for my child to participate in any and all children and youth activities sponsored by Little River United Church of Christ during the 2017-2018 program year.

Yes

No

Additionally *

I understand that all reasonable safety precautions will be taken by the leaders of any activity, and that the possibility of an unforeseen hazard does exist. I further agree not to hold Little River United Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the child listed on this form. I further understand that participation in activities may involve travel. I give permission for my child to travel to and from such activities.

Yes

No

Authorization for Medical Treatment In Case of an Emergency *

I understand that every reasonable effort will be made to contact me. However, if I cannot be reached, I give permission for any physician, nurse, paramedic and/or medical facility to treat my child with any established or approved medical/surgical procedure necessary to ensure his/her health and safety. This may include hospitalization, anesthesia, surgery, or injections of medications. I agree to hold harmless all medical personnel, including those rendering first aid, in this event.

Yes

Would you be willing to volunteer?

Yes

No

Church School

Leader

Assistant

Substitute

Infant Room

Pilgrim Youth Fellowship

Meal

Driver

Chaperone

First Friday

Group Leader

Kitchen

Games/Crafts

Additional Events

Mission Projects, Christmas Pageant, etc.

Yes