Lititz Kids Alive Registration
Event Dates: October 23 - December 18, 2019
Event Times: 6:00 - 7:15pm
Event Address: 44 E. Orange St. Lititz, PA
Contact us at 717.626.2175 or amber@lititztrinity.org
Contact Information
Child's Name *
Your answer
Grade *
School *
Your answer
Parent/Guardian *
Your answer
Parent/Guardian Phone # *
Your answer
Parent/Guardian Email *
Your answer
Emergency Contact *
Your answer
Emergency Contact Phone # *
Your answer
Child's Physician *
Your answer
Physician's Phone # *
Your answer
Physician's Address *
Your answer
Child's Allergies *
Your answer
Child's Meds *
Your answer
Permission for Emergency Medical Care:
By my signature on this form, I give permission to Lititz Kids Alive director/staff that in case of an emergency, and if I cannot be contacted, my child may be taken to the nearest hospital for treatment. *
Required
By my signature below in this form, I, the parent/legal guardian grant permission for my child to participate in Lititz Kids Alive programming. I do not hold Lititz Kids Alive staff or volunteers responsible for any injuries, sickness, or other medical concerns that happen during the time of programming. *
Required
I give my permission for Lititz Kids Alive to use my child's photo, video, and name in any article to be displayed in the church on or church media *
Required
Electronic Signature *
We ask that you physically sign the release form the first time your child attends LKA.
Your answer
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