| A separate registration form must be completed for each participant. |
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| *Cell Phone: |
(______)______-________ |
| *Email: |
__________________________________ |
| *Do you attend Warren Baptist Church?: |
Yes
No (circle one) |
| *If no, what church do you attend?: |
__________________________________ |
| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Birthday: |
__________________________________ |
| *Last Grade Completed: |
__________________________________ |
| *Medical Info: |
__________________________________ |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| ADDITIONAL INFORMATION |
| Registration is open for children Entering Pre-K4 - Completed Grade 5. Children entering Pre-K4 must be four years old on or before September 1, 2022. |
| By registering your child for Backyard Kids Club, you give permission for your child to be photographed and/or videotaped for Warren Baptist Church's promotional materials and social media. If for any reason your child's photo may not be used, you must email kids@warrenbaptist.org with your child's name, host home, and a clear image of your child. |
| By marking yes, you are acknowledging you have read and agree with the above information regarding participant age and our photo release.: |
Yes No (circle one) |
| DROP-OFF/PICK-UP |
| Unless given permission to leave unsupervised, a parent/adult (age 16 or older) must sign each child in AND out using the sign-in sheet provided. If someone different will be picking up your child, please provide their name at drop-off. |
| *Does your child have permission to leave without being picked up by a parent or adult?: |
Yes. They may leave on their own.
No. They must wait on a parent/adult for pick-up. (circle one) |
| *Authorized Pickup #1: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| PLEASE READ AND SIGN BELOW. |
| Terms/Conditions: I/We, the parents/guardian of the above-named child(ren), hereby give approval for my/our child to participate in Warren Backyard Kids Club. I/We assume all risk and hazards incidental to such participation. I/We hereby grant permission for any church staff or adult volunteer present to obtain necessary medical, dental, or mental health treatment in case of sickness or injury to my child when I/We are not available and agree I/We shall be financially liable for said treatment and agree to indemnify and hold harmless the BKC Host Homeowners and Warren Baptist Church, its staff, and adult volunteers for any such treatment. I/We do verify that the above information is correct and waive, release, absolve, indemnify, and agree to hold harmless the BKC Host Homeowners and Warren Baptist Church, its staff, volunteers, and chaperones from any claims, demands, and actions arising out of damage or injury to my/our child while participating. |
| By submitting this registration, you agree to the terms and conditions listed above. |
