2017 CLUB M.A.D Registration Form
The first day of Club MAD (Music, Art, And Drama) is Wednesday, September 6, 2017. Club MAD buses will pick up at
3:00 pm from the schools and end at 5:15 pm. If room is available, children may sign up throughout the semester. Children are placed in one of the choirs by grade in school. All Club MAD leaders and shepherds have completed Ministry Safe Training.
Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Parents Name *
Your answer
Parents Name
Your answer
Address (please include city, state and zip code) *
Your answer
Home Phone Number *
Your answer
Parents Phone at work *
Your answer
Parents Alternate Phone
Your answer
Child's Birthday *
MM
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DD
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YYYY
Gender *
T-Shirt Size *
Grade child will enter in Fall 2017 *
School Child attends *
Your answer
Height of Child (in inches) *
Your answer
Does your Child participate in this area in school: Please select what applies)
Does your Child play a musical instrument:
If so, What?
Your answer
Note: We will have as many as 5 parties throughout the year. Please number in order of preference the parties for which you would like to assist: I can assist with:
Would you consider being a choir mom or dad?
Annual Tuition per child is $30 (includes t-shirt, supplies, etc) Maximum tuition per family is $45.00. If scholarship assistance is needed, please contact Linda Hatfield at 817-326-4242. Please note which tuition applies to you: *
Who will pick up your child? If multiple people will be picking up your child or children, we must have a list of their names and phone numbers or we will not be able to release your children to them. We will ask to see driver's license if we do not know them. Please provide names and phone numbers here.
Your answer
Allergies (Include Food Allergies) *
Your answer
Explain Allergic reaction
Your answer
Alternate Contact Name *
Your answer
Alternate Contact Number *
Your answer
Primary Physician Name *
Your answer
Primary Physicians Phone Number *
Your answer
Are shots up to date? *
There will be times when we take the Club MAD children on field trips. I give Acton Methodist permission to take my child(ren) on the field trip. *
I give Acton Methodist permission to transport my child(ren) in our church bus after school or for field trips. I understand I will be notified in advance any time a field trip is planned. *
Bus will pick up from (parents pick up children at 5:15pm in the CLC, our gym) *Capacity for our buses is 68 children after that is reached parents will be asked to provide transportation to the church. *
Statement of Treatment / Medical and photo release. In case or needed emergency medical treatment, I hereby give permission to the physician selected by Acton United Methodist Church to secure treatment for my child, as named above. I further authorize Lake Granbury Hospital to release pertinent information to Acton staff for the purpose of parental/guardian notification. I recognize the natural risks of injury or disability inherent in my child's participation in Club M.A.D. at Acton Methodist and hereby assume the risk of injury that could result from these activities. I release Acton United Methodist Church, their staff, and volunteers from liability for injury to my child from participation in these and other programs. I give permission for my child's photo(s) to be utilized at the discretion of Acton United Methodist Church staff, which includes the Acton United Methodist Church website. I understand that no names will be used with the photographs. Please type parent/guardian full legal name to serve as an electronic signature* *
Your answer
A copy of your responses will be emailed to the address you provided.
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