| **Registration open to kids entering Pre-K4 to completed 5th grade** |
| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Birthday: |
__________________________________ |
| *Last Grade Completed: |
__________________________________ |
| *Parent/Guardian Name: |
__________________________________ |
| *Email: |
__________________________________ |
| *Cell Phone: |
(______)______-________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| Allergies, Medical, & Special Needs: |
|
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Do you attend Church?: |
Yes No (circle one) |
| If so, where?: |
__________________________________ |
| Comments: |
|
| Photography and video recording may take place during Backyard Kids Club and may be used for Warren promotional purposes and social media. By registering your child, you are giving permission for your child's photo/video to be used in church publications and on social media. |
| 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 Warren Baptist Church/Warren Grovetown, 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 Warren Baptist Church/Warren Grovetown, its staff, volunteers, and chaperones from any claims, demands, and actions arising out of damage or injury to my/our child while participating, whether the result of negligence or for any other cause. |
| By submitting this registration, you agree to the photo/video release and terms and conditions listed above. |
