Viking Kids Club 2018-2019
Thanks for signing up for Viking Kids Club this year! We are so excited to have you! Please fill out the information below to register your child. The excitement begins on September 26th!
Email address *
Child's Name *
Your answer
Grade *
Child's Birthday *
Your answer
Full Address: *
Your answer
Parent/Guardian Name: *
Your answer
Parent/Guardian Phone Number: *
Your answer
Alternative Adult Name: *
Your answer
Alternative Adult Phone Number: *
Your answer
Health or Medical Needs *
Your answer
May we use your child's photo in publications? *
At 2:30 p.m. my child will be: *
If walked home - What is the address to be walked home to>
Your answer
Behavior Agreement
Viking Kids Club is a Volunteer run, free of cost, Christian Ministry of Luther Memorial Church and Grand View University. We seek to create a positive, fun, learning environment for all children involved. We appreciate your partnership for this goal. If there is a case where behavior needs correction, on the first instance of negative choices a parent will be contacted by VKC staff. For the second, the child will be asked to take a week off from VKC. For the third instance, the child will no longer be able to participate in Viking Kids Club.
Do you agree to the Behavior Agreement? *
Liability Agreement
As the parent or guardian of this child, I agree to indemnify and hold harmless Grand View University, Luther Memorial Church, and any of its agents, employees, or representatives for any injury or loss suffered by me due to my participation in the activity or activities specified above (hereinafter collectively referred to as “activity”). I hereby agree that I have been fully advised of the nature and extent of the activity that may take place and represent to you that I am physically and mentally able to participate in the activity without special accommodations or additional supervision. I further understand that I am responsible for any costs incurred and associated with the premature termination or dismissal from the above activity. I understand that the activity may present the risk of injury, or even death, to me, and I have been fully advised of those possibilities. I represent to you that I fully assume the risk of any such injury or death, and I hold you, your agents, employees, and representatives harmless from any liability or death to me while engaged in this activity that is caused or contributed to by my conduct or the conduct of any other participants. I further agree to indemnify and defend you, your agents, employees, and representatives against any claim or liability asserted for any such injury or death.I also hold you, your agents, employees, and representatives harmless from all liability to any other person or entity arising as a result of the conduct of myself or the other participants in the activity and I agree to defend and indemnify you, your agents, employees, and representatives against any claim or liability arising as a result of such conduct.If I am not able to be consulted for any reason in the case of an emergency or necessity arising during the course of the activity or as a result of the activity, I authorize you to contact the emergency contact person or persons listed above and to arrange for such medical and hospital treatment as you may deem to be advisable for my health and well being.
Do you agree to the Liability Agreement? *
Required
What else can we know about your child?
Your answer
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