Kidz Klub Registration – Planned return after summer break 2021

Child Name *

First

Last

Child's D.O.B. & Current Grade

Second Child Name

First

Last

Child's D.O.B and Current Grade

Third Child Name

First

Last

Child's D.O.B and Current Grade

Address *

Home Phone: *

Cell Phone:

Email *

Parent/Guardian Name *

First

Last

Parent/Guardian Name

First

Last

In case of emergency contact name and number:

Medical / Dietary information we should know about:

My child has permission to sign in and sign out:

My child has permission to walk alone:

My child will be brought and picked up by: (list all persons) *

I consent for my child's picture to be taken and used to promote Stayner EMC ministries *

I DO NOT consent
I DO consent

(This could be within a church meeting or event or on church social media and flyers)

SEMC has taken all resaonlable precautions to provide a safe environment for our child(ren). In the even of injury or sickness, SEMC and its volunteers are hereby released from any liability. In the event of an accident all reasonable measures will be taken to contact the parents / guardians and provide appropriate medical attention. *

I have read and understood the above statement

Phone