NLPC Children's/Student's Program Registration Form
School Attended By Child:
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Grade Level:
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For any of the following:
Required
Child's Name:
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Date of Birth:
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Name of Parent/Guardian:
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Address:
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Email Address:
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Phone Number:
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Known Allergies:
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Special Needs:
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Other information that may be helpful for workers in providing care:
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Below are the authorized person/persons who may pick up my child:
Name:
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Relationship:
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Name:
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Relationship:
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Name:
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Relationship:
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Note: Any unfamiliar person will be required to show identification. Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent/guardian. A minor cannot pick up children.
RELEASE FOR MINOR CHILDREN
I, (name)
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parent or official guardian of (child's name)
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hereby grant permission to NLPC, its employees or representatives, to take and use photographs/digital images, videotape, audio recording or quoted remarks of my child for use in church promotional or educational materials.
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Date:
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Signature of Parent or Guardian:
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EMERGENCY MEDICAL CONSENT
North Lake Presbyterian Church has my permission to obtain emergency medical treatment for my child,
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when I cannot be reached or if a delay in reaching my child would be dangerous for him/her.
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Mother/Guardian's Name:
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Home Phone:
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Mobile:
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Email Address:
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Father/Guardian's Name:
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Home Phone:
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Mobile Phone:
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Email Address:
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My family physician is:
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My insurance provider is:
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My child has the following allergies:
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My child is taking the following medications:
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I understand that I assume all financial responsibility for any treatment or injuries sustained by my child.
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I understand that I assume all financial responsibility for any treatment or injuries sustained by my child.
I also give permission for my child/youth to be transported to and from church sponsored activities in a church, rental, or private vehicle.
I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge North Lake Presbyterian Church from any and all claims, demands, actions or causes of action, past, present, or future arising out of any damage or injury while participating in a church-sponsored youth activity.
Signature of Parent or Guardian:
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Date:
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