JK Movement General Registration
The JK Movement Sign-Up
Email Address *
Child's Name *
Grade *
Birth Date *
MM
/
DD
/
YYYY
Home Address *
Parent/Guardian Name *
Home/Cell Phone *
Emergency Contact Name *
Emergency Contact Home/Cell Phone *
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? *
Is your child allergic to any type of food or medication? *
Photo Release: I hereby give permission for my child to be photographed during The JK Movement Program. I understand the photos will be used to keep a journal of activities, to share during PowerPoint presentations and/or reports to our donors, and for promotional purposes including flyers, brochures, newspapers, and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of The JK Movement and its affiliates. *
Transportation Release: I hereby give permission for the transportation of my child for official The JK Movement activities by modes of transportation agreed to by the camp organizers. * *
The JK Movement and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician's orders. Children's' photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy