Child Name *

First Name

Last Name

Gender: *

Male

Female

Date of Birth: *

MM

DD

YYYY

Grade: *

PreK

Kindergarten

1st

2nd

3rd

4th

5th

6th

Parent / Guardian Name: *

First Name

Last Name

Primary Phone Number: *

(###)

###

####

Secondary Phone Number:

(###)

###

####

Mailing Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Alternative Pickup Person:

First Name

Last Name

Phone Number of Alternative Pickup Person:

(###)

###

####

Medical Release *

I give permission for the Kids' Club staff to administer basic first aid to my child (named above) in the event of an injury. I understand that the Kids' Club staff will contact emergency services in the event of a significant injury and all expenses for such emergency will be paid by me.

Photo Release

I hereby grant Christ Community Church permission to copyright and use photographs/videos taken at Kids' Club of the minor designated above in any manner or form for any purpose lawful at any time. I waive any right that I may have to inspect or approve the finished product or written copy, that may be used in conjunction therewith, or the use to which it may be applied.

Permission to Attend *

I give permission for my child (named above) to attend Kids' Club at Christ Community Church. I understand that the information I give for this registration will only be used by Christ Community Church.