Panda Mania! KPC Registration Form 2014 - 2015
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Parental Consent and Liability Statement
On behalf of our child, we do hereby release, forever discharge and agree to
hold harmless,the Fluvanna Community Church and the directors thereof
from any and all liability, claims or demands for personal injury, sickness or
death, as well as property damage and expenses of any nature whatsoever
which may be in current by child-participant while participating in church-
sponsored activities. On behalf of our child we hereby assume all risk of
personal injury, sickness, death, damage, and expense as a result of
participation in recreation and work activities involved therein. Further,
authorization and permission is hereby given to said church to furnish any
necessary transportation and food for this participant in any way as
necessary.
By Checking this box, you are
acknowledging that you have read
and agree with the Parental
Consent and Liability Statement.
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First Name
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City
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Main Phone
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Cell Phone
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Date of Birth
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Parents Name
Grade
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Parent's Email
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allergies or other health issues.
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