EmailMe Form - Kids Club Registration

I am registering my child for: *

Kids Club Sunday

Kids Club Tuesday

Please select the number of children you're registering: *

Name of First Child *

First Last

Gender *

Male

Female

Date of Birth *

DD / MM / YYYY

Grade *

Allergies or other medical concerns

Behavioural or social concerns

Photo Upload

Photos submitted here will be used for your child's Kids Club Sunday membership card.

Name of Second Child *

First Last

Gender *

Male

Female

Date of Birth *

DD / MM / YYYY

Grade *

Please choose your child's activity for the Winter term (Tuesdays only) *

Allergies or other medical concerns

Behavioural or social concerns

Photo Upload

Photos submitted here will be used for your child's Kids Club Sunday membership card.

Name of Third Child *

First Last

Gender *

Male

Female

Date of Birth *

DD / MM / YYYY

Grade *

Allergies or other medical concerns

Behavioural or social concerns

Photo Upload

Photos submitted here will be used for your child's Kids Club Sunday membership card.

Name of Fourth Child *

First Last

Gender *

Male

Female

Date of Birth *

DD / MM / YYYY

Grade *

Allergies or other medical concerns

Behavioural or social concerns

Photo Upload

Photos submitted here will be used for your child's Kids Club Sunday membership card.

Name of Fifth Child *

First Last

Gender *

Male

Female

Date of Birth *

DD / MM / YYYY

Grade *

Allergies or other medical concerns

Behavioural or social concerns

Photo Upload

Photos submitted here will be used for your child's Kids Club Sunday membership card.

Do you currently attend a church? If so, please specify *

Address (including PO Box #) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Email Address

We send out periodic emails to keep parents updated on events and activities happening related to Kids Club. You can opt out of these emails at any time.

Home Phone *

### - ### - ####

Cell Phone

### - ### - ####

Names of Parents/Guardians (who the child lives with) *

Emergency Contact *

Emergency Contact # *

### - ### - ####

Are there any security or custody restrictions that we need to be aware of?

Pickup Information

We ask that only the people listed below pick up your children from Kids Club. If there are any changes, please bring them in writing at your earliest convenience.

Any changes to this information must be made in writing when you drop your child off.

Name *

Relationship to child *

Name

Relationship to child

Name

Relationship to child

By clicking "Agree," I/We, the parents or guardians named above, authorize the pastoral staff of Glad Tidings Community Church to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above in the event that I/we cannot be reached in a timely manner.

I/We, named above, undertake and agree to indemnify and hold blameless the ministry staff, Glad Tidings Community Church, its pastors and Board from and against any loss, damage, or injury suffered by the participant as a result of being part of the activities of Glad Tidings Community Church, as well as of any medical treatment authorized by the supervising individuals representing the Church. This consent and authorization is effective only when participating in or traveling to events of Glad Tidings Community Church.

Parental Consent & Medical Release *

Agree

Pictures and videos may be taken from time to time. These pictures and videos may be used in print or on social media and the Internet to show events that have taken place.

Due to the proliferation of still cameras, video cameras, and cameras in mobile devices (cell phones, tablets, etc.), Glad Tidings Community Church cannot regulate pictures or videos taken by other participants at its events. Children may appear in pictures or videos of activities that may be published or posted in venues (such as the Internet, social media, etc.) which are not under the control of Glad Tidings Community Church. As such, Glad Tidings Community Church cannot take responsibility for such actions.

Photo Consent *

Agree

Disagree