KidZone Connect Registration

KidZone Connect Registration Form

Parent Contact Info
Parent/ Guardian #1 Name*
First Last
Parent/ Gardian #1 Email*
Parent/ Guardian #1 Phone*
Parent/ Guardian #1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact
Name*
First Last
Relationship to Child(ren)*
Phone #1*
Number of Child(ren)*
Child #1
Name of First Child*
First Last
Gender
Age of First Child*
Please enter a number from 4 to 12.
KidZone Connect is for children ages 4 through 5th grade.
Any food allergies for first child?
Any medical conditions that we should know about regarding first child?
Child #2
Name of Second Child
First Last
Gender
Age of Second Child
Please enter a number from 4 to 12.
KidZone Connect is for children ages 4 through 5th grade.
Any food allergies for second child?
Any medical conditions that we should know about regarding second child?
Child #3
Name of Third Child
First Last
Gender
Age of Third Child
Please enter a number from 4 to 12.
KidZone Connect is for children ages 4 through 5th grade.
Any food allergies for third child?
Any medical conditions that we should know about regarding third child?
Child #4
Name of Fourth Child
First Last
Gender
Age of Fourth Child
Please enter a number from 4 to 12.
KidZone Connect is for children ages 4 through 5th grade.
Any food allergies for fourth child?
Any medical conditions that we should know about regarding fourth child?
Child #5
Name of Fifth Child
First Last
Gender
Age of Fifth Child
Please enter a number from 4 to 12.
KidZone Connect is for children ages 4 through 5th grade.
Any food allergies for fifth child?
Any medical conditions that we should know about regarding the fifth child?
CHILD PICK UP AUTHORIZATION
Name of Child(ren):*
AUTHORIZED PICK-UP PERSON:
Name | 1*
First Last
Relationship to Child | 1*
Phone | 1*
Name | 2
First Last
Relationship to Child | 2
Phone | 2
- In my registration of my child/children for KidZone Connect, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance Gashland EPC, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.
- In addition, I hereby authorize Gashland Evangelical Presbyterian Church to publish photographs and videos taken of me and/or the undersigned minor children, and our names, for use in the Gashland Evangelical Presbyterian Church’s printed publications, website and training purposes. I release Gashland Evangelical Presbyterian Church from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed above and that I have the authority to authorize GEPC to use their photographs, videos, and names. I acknowledge that since participation in publications and websites produced by Gashland Evangelical Presbyterian Church is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by Gashland Evangelical Presbyterian Church confers no rights of ownership whatsoever. I release Gashland Evangelical Presbyterian Church, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.
- I understand that:
  - The “Authorized Pick-Up Person” must be at least 18 years old and must provide a photo ID to the staff.
  - This authorization shall remain in force until edited or rescinded in writing by the signers of this authorization.
Consent*
I agree to the above policy.

Parent Contact Info

Emergency Contact

Child #1

Child #2

Child #3

Child #4

Child #5

CHILD PICK UP AUTHORIZATION