Kids at the Creek Info Sheet 9/2018-8/2019
Information form and medical/media release for all kids at SCPC
Thanks!
Last Name *
Your answer
Parents First Name *
Your answer
Address *
Your answer
Cell Phone # *
Your answer
Home Phone #
Your answer
Email *
Your answer
1 Child's Name *
Your answer
Allergies/ Medical Conditions *
Your answer
Birthday *
MM
/
DD
/
YYYY
School & Grade *
Your answer
If your child has an IEP in school, please let us know any accommodations we can make that would be beneficial to them.
Your answer
Activities, Sports or Hobbies this child participates in that Wendy might be able to watch: (please list Fall, Winter, Spring & Summer seperately)
Your answer
2 Child's Name
Your answer
Allergies/ Medical Conditions
Your answer
Birthday
MM
/
DD
/
YYYY
School & Grade
Your answer
If your child has an IEP in school, please let us know any accommodations we can make that would be beneficial to them.
Your answer
Activities, Sports or Hobbies this child participates in that Wendy might be able to watch: (please list Fall, Winter, Spring & Summer seperately)
Your answer
3 Child's Name
Your answer
Allergies/ Medical Conditions
Your answer
Birthday
MM
/
DD
/
YYYY
School & Grade
Your answer
If your child has an IEP in school, please let us know any accommodations we can make that would be beneficial to them.
Your answer
Activities, Sports or Hobbies this child participates in that Wendy might be able to watch: (please list Fall, Winter, Spring & Summer seperately)
Your answer
Kids' Sunday Club 10 am each Sunday, will your child(ren) be joining us?
LIABILITY RELEASE Every activity sponsored by SCPC is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By agreeing to this question, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree to hold SCPC, or its employees or volunteer assistants harmless for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are agreeing for the minor listed on this form and the signature is for both a medical and liability release. Our church’s insurance is excess insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is participating in a church-related activity. In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary. *
Required
MEDIA CONSENT I give my consent and permission for the taking of photographs and/or video of my child for September 2018 - August 2019 and waive and/or assign any and all rights (including copyright) in such media to SCPC for promotional use in print and online. SCPC will not use their full names with the picture of the students on their website, nor will it tag any children used on SCPC or Kids at the Creek facebook pages. *
Required
Date *
Your answer
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