Child #1 Name

First Name

Last Name

Child #2 Name

First Name

Last Name

Child #3 Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone #1

(###)

###

####

Best Phone #2

(###)

###

####

Emergency Contact

in the event of emergency and parent/guardian cannot be reached

First Name

Last Name

Emergency Phone

(###)

###

####

Medical Release *

I understand that every precaution will be taken for the safety and well-being of my child(ren). In the event of an accident or sickness, however The Community Chapel, its staff and volunteers are hereby released from any and all liability with the above activity by The Community Chapel, its staff, volunteers, or agents. In case of medical emergency, I understand that hospital policy requires parent/guardian permission before treatment. I hereby give permission to a representative of The Community Chapel to secure proper medical treatment if a parent or guardian cannot be reached.

Yes

Photo/Video Release *

I agree to and realize that my child(ren)'s photograph or video may be taken during the event. I waive the right to inspect or approve the image if used for publications or publicity in social media or print.

Yes

No