Children's & Youth Programs Registration 2019-2020
Burke United Methodist Church
Email address *
Membership *
Child #1 Name *
Your answer
Child #1 Date of Birth *
MM
/
DD
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YYYY
Child #1 Grade *
Child #1 Personal Email (if over age 10)
Your answer
Child #2 Name
Your answer
Child #2 Date of Birth
MM
/
DD
/
YYYY
Child #2 Grade
Child #2 Personal Email (if over age 10)
Your answer
Child #3 Name
Your answer
Child #3 Date of Birth
MM
/
DD
/
YYYY
Child #3 Grade
Child #3 Personal Email (if over age 10)
Your answer
Child #4 Name
Your answer
Child #4 Date of Birth
MM
/
DD
/
YYYY
Child #4 Grade
Child #4 Personal Email (if over age 10)
Your answer
Children/Youth Cell phone # (if over age 10) - we use this for group texting and reminders about programs/events. List child's first name with 10 digit phone # and separate multiple entries with commas.
Your answer
List any other information about each child if applicable; separate children's names and conditions using a comma. (Allergies, Medical Diagnosis, Learning Strategies, etc)
Your answer
List all individuals authorized to pick-up children/youth (Students in grades 7th and older may be listed to pick-up their younger siblings) *
Your answer
Parents'/Guardians' Names *
Your answer
Complete Home Mailing Address: *
Your answer
Home Phone Number *
Your answer
Parent/Guardian Cell Phone Number *
Your answer
Parent/Guardian Volunteer Opportunities *
Required
Your initials below indicate that you understand and agree to the following statements: I understand that 7-12th grade students will be released at the end of the Sunday School hour. Nursery – 6th grade students will only be released to an adult or older sibling whose name is listed on the child’s registration form. Any changes must be communicated to the Children's Ministry Coordinator or Youth Ministry Coordinator. I give permission to Burke United Methodist to photograph and video record my child at BUMC church activities. I give permission for BUMC to copyright, use, and publish the photographs and video for any lawful purpose, including newspaper articles, church publications, and the church website. BUMC Minor Participation Authorization and Consent to Emergency Medical Treatment Form, the undersigned, certify that I am the parent or legal guardian of the minor children listed on this form.I hereby give my consent to have my minor child participate in the activities of Burke United Methodist Church (hereafter “the activity”). I recognize that there are risks involved in participating in this activity and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in this activity. To the fullest extent permitted by law, I release Burke United Methodist Church its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Burke United Methodist Church its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity. Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage. Initial Below: *
Your answer
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