Summer Break 2019 Registration
Event Timing: July 22nd-25th, 2019
Event Address: 903 Center St, Bryan, OH 43506
Contact us at (419) 633-2806 or
https://www.facebook.com/SummerBreakBryanOH/
How did you hear about Summer Break? *
Your answer
Child 1 Name *
Your answer
Age Group *
Child 2 Name
Your answer
Age Group
Child 3 Name
Your answer
Age Group
Child 4 Name
Your answer
Age Group
Full Address *
Your answer
Parent/Legal Guardian Name *
Your answer
Parent/Legal Guardian Relationship *
Parent/Legal Guardian Email *
Your answer
Cell Number (no dash or space) *
Your answer
Other Parent/Legal Guardian Name
Your answer
Other Parent/Legal Guardian Type
Other Cell Number
Your answer
Do you attend a Church? *
Church's Name *
If None type "None"
Your answer
Emergency Contact Name *
Other than Parents in case parents cannot be reached.
Your answer
Emergency Contact Number (no dash or space) *
Your answer
Emergency Contact Relationship to Child *
Your answer
Does Your Child Have an Allergy, Medication, or Require Any Special Accommodations? *
Medication that might be needed during the Summer Break event.
Allergy / Medication / Accomodation *
If None put "None" in the box (Please include: Rescue Inhaler, Epi-pen, DISATAT AcuDial, or other emergency medication)
Your answer
Parent/Guardian Agreement: I give permission for my child to participate in the Summer Break 2019 program in Bryan, OH. I understand that my child will be participating in group games, and other physical activities. I hereby release Wesley United Methodist Church, First Assembly of God, it's staff, partners, volunteers, and affiliates from any liability should my child be injured or otherwise as a result of participating in this program. Summer Break 2019 partners do their best to make sure materials used for Summer Break are washable, but we cannot guarantee that all items used will not stain clothing. I also understand that the Summer Break Team will be photographing and taking video footage of Summer Break 2019. I understand my child may be photographed or recorded during this event. Summer Break 2019 reserves the right to use photographs and video footage for promotional purposes, and I understand that no compensation will be offered for use of this media. *
Electronic Signature *
First Name and Last Name
Your answer
Submit
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