Kidron Mennonite Church Youth Programs Participation Registration
Child's first and last name *
Your answer
Child's birth date *
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Last grade completed *
Child's gender *
Child's address *
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Mother's/female guardian's name and phone number *
Your answer
Father's/male guardian's name and phone number *
Your answer
If your child comes to activities with a mentor or friend, please list the name and phone number of the mentor or friend.
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Emergency contact name, relationship, phone number *
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Transportation and release instructions. Check all that apply. *
Required
Names of person(s) authorized to pick up your child *
Your answer
Facts concerning the child's medical history, including allergies, medications being taken, physical or mental/emotional concerns that may impact participation.
Your answer
Name and phone number of preferred doctor *
Your answer
Name and phone number of preferred dentist *
Your answer
I have read and understand the KMC Children's Ministries Statement of Policies. Read the statement at kidronmennonite.com/forming-faith *
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Photo release *
General Liability Release for all KMC sponsored activities Acknowledgment of Risk: While the above activities can be fun, I understand that they involve certain risks. I have carefully considered the risks involved and consent to my child’s participation in the above activities. I understand that participation in the above activities is entirely voluntary and participants, including my child, must abide by applicable rules and standards of conduct. I understand that the above activities may require my child or children to be transported by Kidron Mennonite Church’s staff or volunteers. Release from Liability: I release Kidron Mennonite Church, its staff, its volunteers, and other persons or organizations associated with the above activities from all claims arising out of my child’s participation in the above activities or transportation incident to such participation. Indemnification: Further, I agree to indemnify Kidron Mennonite Church, its staff, its volunteers, and any other persons or organizations associated with the above activities against any claims for injury, death, or property damage brought by or on behalf of my child as a result of participation in the above activities. *
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Your answer
Consent to medical treatment: I authorize and consent to any diagnostic examinations, administration of anesthetics and/or drugs, medical and/or surgical treatment, and hospital care required to be rendered to our child under the general or special supervision and on the advice of physicians, surgeons, anesthesiologists, dentists, or ophthalmologists licensed in the location where treatment is rendered, or by other qualified medical personnel acting under their supervision. We further consent to the release of any medical records and medical information for our child between any medical providers under this Consent and our child’s customary medical providers and any Kidron Mennonite Church staff or volunteer accompanying our child in seeking treatment while such child is under the authority of Kidron Mennonite Church, its staff and volunteers (collectively “Church”). Minor treatment not normally requiring a physician and life-saving emergency treatment may be rendered to our child by any person. Notification. With the exceptions of minor treatment not normally requiring a physician and life saving emergency treatment, reasonable attempts to reach me or another parent or guardian at the numbers listed above shall be made by such treating person or facility prior to such treatment if notification will not jeopardize our child’s good health, or immediately after such treatment if the delay for notification may jeopardize his/her good health. Major surgery should not be conducted without the consent of one of the undersigned unless at least one other qualified (physician, dentist, ophthalmologist, or other licensed professional according to the situation) medical opinion concurs with the need for such immediate major surgery without the consent of one of the undersigned. Indemnification. I further agree to indemnify the Church against any claims by my child or other parent or guardian for the Church consenting to treatment on my child’s behalf in compliance with this document’s terms. *
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