God's Kids Club & 4JC Registration
2018-2019 School Year - Living Life Reformed Church
Parent or Guardian's names: *
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Primary email contact *
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Address:
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School:
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Home phone:
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Church (if applicable)
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Mother's Name / Cell Phone / Email
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Father's Name / Cell Phone / Email
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Child #1 Name / Gender / Birthdate / Grade *
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Child #2 Name / Gender / Birthdate / Grade
Your answer
Child #3 Name / Gender / Birthdate / Grade
Your answer
Child #4 Name / Gender / Birthdate / Grade
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Child #5 Name / Gender / Birthdate / Grade
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List any allergies or other restrictions which may hinder your child's ability to fully participate in all GKC & 4JC activities. Include pertinent physical, psychiatric and behavior related information.
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Parental Consent
My child has permission, without restriction, to participate in all snacks, regular and special programming (including transportation), unless I notify LLRC in writing. I understand and realize Living Life Reformed Church will follow safety procedures, but that all physical activities include a certain risk and that LLRC assumes no liability for injury or damage arising from, or as a result of, participation. I affirm that I have been advised that any and all church activities include risks and dangers. These risks include, but are not limited to, loss of or damage to personal property, injury or fatality. I have assumed all of the above risks and intending to be legally bound hereby, will hold Living Life Reformed Church and their agents, servants, and employees harmless from any liability which may arise out of, or in connection with, any trips and related participation in any other activities arranged for by Living Life Reformed Church, their agents, servants and employees. The terms hereof shall serve as a RELEASE AND ASSUMPTION OF RISK for any minors.

In the event that I cannot be reached in an emergency, I herby give permission to the physician or dentist selected by LLRC to hospitalize, secure proper treatment for, and order injections, anesthesia, or surgery for my child. My child's physician or his/her office should be contacted, if possible.

I understand that GKC/4JC?LLRC reserves the right to dismiss any child if it is deemed necessary by the directors to be in the best interest of the child or program.

I give permission for Living Life Reformed Church to use my child's name, voice, testimonial, and/or picture in any type of promotional material, press release and news stories about God's Kids Club, 4JC's or Living Life Reformed Church. I understand I can notify a director if this is unacceptable.

I have read and agree to the above and assume responsibility for my child and his/her actions. *
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Name of person completing this form *
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