KidZone Registration

Please complete one form per child. Thank you!

Name

Gender

Male Female

Birth Date

Grade

KidZone Area

Allergies/Medical Conditions

Contact Information

This address will receive a confirmation email

Mobile Phone

Address

Parent(s) Names

Important! Please read carefully.

RELEASE AND PERMISSION STATEMENT I/we, the parents or guardians named above, authorize the University Drive Alliance Church pastoral staff to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above. I/we, named above, undertake and agree to indemnify and hold blameless Pastoral Staff, the Ministry Staff, University Drive Alliance Church, and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the University Drive Alliance Church, as well as of any medical treatment authorized by the supervising individuals representing the church. The consent and authorization is effective only when participating in or traveling to events of the University Drive Alliance Church.

I agree

Allow Photo/Video Footage? Occasionally we will use photos/ video footage of our programming as promotional material in the church and on our website. We do not attach names or personal information to the images/footage.

Yes No

Purposes and Extent. All of the information above will be used for church purposes only. Would you like your name and information also added to the church directory?

Yes No

KidZone Registration

Description

Please Fix the Following