Mason Community Church Children's Ministry Registration Form

Thank you for registering your child in the Mason Community Church (MCC) Children's Ministry.
A parent or legal guardian should fill out a separate original form for each child involved in a MCC Children's Ministry program or activity so we can best serve you and your family. Completion of this form will be valid for our children's ministry and any other programs/events sponsored by the Mason Community Church Children's Ministry during the 2018-2019 school year.

1000 E. Columbia Street
Mason, MI 48854
(517) 676-5322

CHILD'S INFORMATION
Child's Name (Last, First) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Required
Street Address / City *
Your answer
GRADE: School Year 2017-2018 *
FAMILY INFORMATION
Mother's Name (Last, First) *
Your answer
Mother's Phone *
Your answer
Father's Name (Last, First)
Your answer
Father's Phone
Your answer
Guardian(s) Name(s) (Last, First)
Your answer
Guardian(s) Phone
Your answer
Contact Email *
Your answer
Please list any additional adults your child may be released to (name, relationship):
Your answer
Please list any adults your child may not be released to (name, relationship):
Your answer
EMERGENCY INFORMATION
Emergency Contact (name, relationship) *
Your answer
Emergency Contact Phone *
Your answer
Family Doctor (name & phone) *
Your answer
Any known allergies (list below) *
Your answer
Medications (include over-the-counter) *
Your answer
PROGRAM INVOLVEMENT
YES, my child may participate in the following: *
Required
We attend church . . . *
We attend church at . . .
Your answer
RELEASE and MEDICAL AUTHORIZATION
I give permission for Mason Community Church to use photographs, videos, images of my child in printed or electronic publications of the church. *
Required
I certify that I have the right to consent to medical treatment of the child named on this form. If I cannot be reached in an emergency, I give permission to the physician selected by Mason Community Church (MCC) Staff to make the decisions necessary for treatment. I agree that MCC, its members, employees, agents, and volunteers shall not be liable for damages, losses, diseases, injuries, or death incurred by the child named on this form so long as the treatment is administered by or under the supervision of a licensed physician. Further, I am ultimately responsible for the health care cost for the above named child and agree to pay for the dental, medical, or hospital care or treatment that is given to my child. I understand that I am responsible for the costs of any medical care not reimbursed by health insurance. *
Required
I am the parent/legal guardian of the above named child and have the authority to consent to the participation of this child in MCC Children’s Ministry. I consent to the participation of my child in the functions, programs, and activities of this ministry during the 2017 - 2018 program year (September through August), including any and all programs and activities customarily associated with MCC children’s group. *
Required
I would like to receive the MCC KidMin Newsletter.
NAME of parent/guardian who completed this form: *
Your answer
FOR OFFICE ONLY:
Your answer
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