Keystone Kids and Youth Registration

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Keystone Kids and Youth Registration



June 2017 – August 2018



Family Registration Information

Father’s Name: ______________________________ Mother’s Name: _____________________________



Home Address: __________________________________________________________________________ Land Line Phone: ________________ Dad’s Cell: _______________ Mom’s Cell: _____________________ Dad’s Email Address: __________________________________________ Mom’s Email Address: __________________________________________ EMERGENCY CONTACT IF PARENTS CANNOT BE REACHED Print Name: _____________________________________ Relationship to Children: _______________________ Phone Number: ________________________________



Form is continued on other side

Name (Include last name if different from parents)

2017 - 2018 Allergies, Special needs Grade

Birthday

Gender



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W AIVER I waive any and all claims against Keystone church, its staff and volunteers, and release them from liability, in the event of accident, damage, injury, or sickness to my child(ren) in connection with my child(ren)’s participation in Keystone Church children and youth programs. I hereby give my permission to Keystone Church to obtain and provide first aid/emergency medical care to my child(ren) as needed during this activity. Publicity Release—There are those occasions when publicity pictures will be taken for newspaper articles, Facebook, keystonechurch.org and Keystone Church promotional and marketing materials. Please initial here if you would not like us to publicize pictures of your child(ren): _________ No, you may not photograph my child(ren)

Signature of parent/guardian: __________________________________ Date: _____________