Registration for Tuesday Night Kids Connect

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Basic Info

Child's Name

First

Last

Child's Gender

Child's Date of Birth

Grade

Church You Currently Attend

Please describe any allergies, medications, medical conditions, physical or behavioral challenges, or other concerns.

Parent/Guardian

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Emergency Information

Alternate Contact Person (in case of emergency)

Emergency Phone Number

Relationship to Child

Legal Stuff

Photos/videos may be taken of my child for craft projects and in-church purposes.

Photos/videos may be taken for use on the church webpage and Facebook.

As a parent or legal guardian of the above child, I authorize a representative of Homewood Evangelical Free Church to consent to all medical treatment as deemed advisable in the opinion of the attending physician in the event of a medical emergency. I give permission for the above named child to participate in all Kids Group activities. I waive and release Homewood Evangelical Free Church and any of its staff and volunteers from any and all liability for injury or illness.

Signature (first and last name)

Signature Date

I agree

By typing my name and checking this box, I am signing this application electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this application.