412 Kids Registration Form
Please fill out this form and click submit.
Student's Name
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Age
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Birth Date
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Grade
*
Brothers and sisters also in 412 Kids (list name and age)
*
Parent or guardian name
*
Email
*
This address will receive a confirmation email
Phone
*
Physical Address
*
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Mailing Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Please list any allergies, medical concerns, or special learning needs
Will your child be taking the school bus to Entiat Warehouse Community Church after school?
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Please select all that apply.
Yes
No
Emergency contact if parent cannot be reached
*
Phone
*
Please list any adults, not previously listed, that are authorized to pick up your children
*
Would you like to volunteer at 412 Kids?
*
Please select all that apply.
Yes
No
WAIVER OF LIABILITY & MEDICAL RELEASE
We understand the arrangement and believe that the necessary precautions and plans for the care and supervision of the child will be taken during the participation in Entiat Warehouse Community Church 412 Kids. Beyond this, we will not hold responsible Entiat Warehouse Community Church or the person supervising the program. In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give the Children's leadership, staff, or other emergency medical personnel the permission to act on my behalf in seeking emergency medical treatment for this child in the event that such treatment is deemed necessary by the volunteer, leadership, or church staff. I give permission to those administering emergency medical treatment to do so using those measures deemed necessary. I absolve Entiat Warehouse Community Church, and/or church personnel from liability in acting on my behalf in this regard so long as they are not grossly negligent. I, as a parent or guardian of a child participating in 412 Kids at Entiat Warehouse Community Church, Entiat, WA, accept the responsibility for all expenses arising from medical care for injuries to my children while participating in these activities. By checking, I agree to the conditions of the Waiver of Liability & Medical Release.
*
Please select all that apply.
Agree
Disagree
PERMISSION TO USE CHILD'S PHOTOS IN PRINT OR ON WEB
My child/children may be photographed or filmed while participating at Entiat Warehouse Community Church. Their photo may be used for promoting or sharing activities from Children's Ministry or church related events, in print materials and/or electronically on the internet. By checking, I agree to the photo policy.
Please select all that apply.
Agree
Disagree
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