Children's Church Registration Form - Laketon Bethel Reformed Church

Child's Name *

Address *

Address 1
Address 2

City

State

Zip

Grade *

Age *

Date of Birth *

Name of Parent(s) or Legal Guardian *

Daytime Phone Number

Evening Phone Number

Email *

Name of Emergency Contact if Parent Can't Be Located:

Phone Number

Relationship

List of allergies or medical conditions

Is staff authorized to administer/authorize treatment? *

PARTICIPATION AGREEMENT

I acknowledge that participation in the Children & Yourth Ministries involves risk to the participant and to the parent/guardian, and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, personal injury, exposure to infectious/communicable disease (COVID-19). You agree to abide by the procedures established by the church to protect attendees and staff, and you voluntarily assume the risk that you and/or your family may be exposed while participating in the Children & Youth programs.

Your typed name below represents your signature.

Signature *

Date *

Enter an email address below where we can send confirmation of registration. Thank You

Enter Your Email Address: *