KidZone Wednesday's Registration

Ages 3yrs - 5th Grade
Program runs Sept. 20th - May 2nd, 6:30pm - 8:15pm
Childcare provided for ages 3mo - 2yrs if you are attending a Wednesday Night Life Group

Mom Name

Dad Name

This address will receive a confirmation email

Mom Cell

Dad Cell

Address

Emergency Contact Name & Phone Number (NOT parent)

Are you attending a Bible Study on Wednesday Nights?

Yes No

Childs Name (first & last)

Birth Date

Allergies (if no allergies then please mark n/a)

Childs Name (first & last)

Birthdate

Allergies (if no allergies then please mark n/a)

Childs Name (first & last)

Birthdate

Allergies (if no allergies then please mark n/a)

Childs Name (first & last)

Birthdate

Allergies (if no allergies then please mark n/a)

Medical Release: In the event of an emergency, I understand that a reasonable effort will be made to contact me. If I cannot be reached, I hereby authorize a representative of Authentic Life Church to act on my behalf to seek emergency medical care or treatment for my child. I further give my permission to any physician or other qualified medical personnel to administer any and all emergency medical care, which they deem necessary (not including vaccines). If I cannot be reached, checking this box will serve as my electronic signature to give my permission for any advisable medical services provided, and I agree to accept liability for payment of those services.

Parent Signature

Video/Photo Release: Authentic Life Church may, at its discretion, take photographs or video of participants at events. The resulting images may be used to promote the event or a similar event in the future and/or to archive the event for historical purposes. By signing below, you give Authentic Life Church your permission to use potential images taken of your child for these purposes.

Parent Signature

KidZone Wednesday's Registration

Description

Please Fix the Following