PowerHouse Registration
PowerHouse is an after-school kids' program offered to students in grades 1-5. The program will take place at Potter's Wheel on Wednesdays from 3:00-5:30 pm. Transportation will be provided.
Email address *
Child's name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Current Grade *
School *
Your answer
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Allergies or Special Needs? *
Your answer
Will transportation be needed? *
Will your child participate in King’s Kids? (A kid’s choir that practices at Crossroads Christian Church. This program does not end until 6:15 pm on Wednesdays) *
Participation and Parental Consent
I give my permission for my child to participate in programming at Potter’s Wheel (aka, The Potter’s Wheel Inc.) or any activity sponsored by Potter’s Wheel, and led by staff and volunteers. I agree to allow photos/videos of my child to be taken, and used in promotional materials as needed. I give my permission for Potter’s Wheel to transport my child in a Potter’s Wheel van or private cars driven by Potter’s Wheel staff or volunteers. I hereby release Potter’s Wheel and all adult leaders from any liability and from any and all claims against them, individually or collectively, for any injuries which might be received during this activity or any field trip, or in traveling to and from such activity.
Medical Authorization

I agree, and by my signature give consent, that in cases of an accident, injury or illness, my child will be given emergency medical care. I understand that staff will contact me as soon as possible in the event professional medical attention is sought for my child. I also consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment and/or hospital care to be rendered to my child, under the general of special supervision of the attending physician/surgeon licensed to practice medicine. Potter’s Wheel does not carry medical insurance for program participants. Consent is active unless revoked in writing by parent/guardian.
Signature of consent *
Your answer
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Potters Wheel. Report Abuse