CAC Kidz Club Registration

Child Registration Form

Child's Name:

Date of Birth: mm/dd/yy

Last Grade Completed:

Age:

Parent / Guardian Name:

Mailing Address:

Email:

This address will receive a confirmation email

Home Phone:

Cell Phone:

Emergency Contact Name & Number:

Special Needs / Allergies / Other Concerns:

Home Church (if you attend locally):

Liability / Photography Release:

I further acknowledge that any child registered on this form, as a participant in Vacation Bible School at Coudersport Alliance Church, may be photographed or captured on video during the Vacation Bible School program and activities. I hereby grant full permission to Coudersport Alliance Church to use photographs or videos in print, electronic, online, or other public media of the child registered on this form and further release Coudersport Alliance Church from any and all liability connected with the authorized use of words and image of the child registered on this form.

I have read and agree to the above Liability Release and Photography/Video Authorization

Yes No

Electronic Signature of Parent / Guardian

Description

Thursdays 6:15pm

This form is designed to register a child for Kidz Club at Coudersport Alliance Church.

CAC Kidz Club Registration

Description

Please Fix the Following