General Information:

Child's Name*:

Date of Birth*: (mm/dd/yyyy)

School Grade for 2016-2017 School Year*: Age*:

Parent/Guardian Name*:

Address*:

City*: State*: Zip Code*:

Phone 1*: Number Type*:

Phone 2: Number Type:

How did you hear about Fun Day?

Health History:

Medical conditions we need to know:

Allergies:

Present Medications:

Emergency Contacts*:

Emergency Contact 1
Name*:

Relation*:

Phone*:

Emergency Contact 2:
Name*:

Relation*:

Phone*:

Dismissal Information:
Only the following individuals will be allowed to pick up this child, NO EXCEPTIONS.

Name*: Relation*:

Name : Relation :

By clicking accept below, I certify the information is true and I agree to the statement below:

Release of Liability
I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the person(s) listed on this form. In the event I (we) cannot be reached, I give my permission for medical treatment to the health care professional selected by the adult leaders at College UMC.

I understand all reasonable safety precautions will be taken at all times by the church and it’s agents during the events and activities. I consent to any organized travel by bus as part of the activities conducted during the event. I agree not to hold the church leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred.

I consent to my child’s picture to be taken and used for promotional or publicity purposes.

I agree

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