Copy of Kidron Mennonite Church Youth Programs Participant Registration

Name of participant

Date of Birth

Gender

Address

Phone

This address will receive a confirmation email

School

Mother/Female Guardian's Name and cell phone number

Father/Male Guardian's Name and cell phone number

If your child comes to activities with a mentor or friend, please list the name and phone number of the mentor or friend.

Emergency Contact name, relationship, phone number

Transportation and Release instructions. Check all that apply. My child may leave on her/his own after activities (children 3rd grade+ only). My child needs to wait with the activity leader to be picked up. My child may ride with staff and volunteers to regularly scheduled activities. My child is a licensed driver and I give permission for her/him to drive other youth for local MYF events. I give permission for my child to ride with a licensed youth, appointed by staff or volunteers, to a local MYF event.

Name of person(s) authorized to pick up your child.

Facts concerning your child's medical history, (including allergies, medications being taken, physical or mental/emotional concerns) that may impact participation.

Preferred Doctor: Name and phone number

Preferred Dentist: Name and phone number

I have read and understand the KMC Children's Ministries Statement of Policies. (Read the statement at kidronmennonite.com/forming-faith ). Please initial:

General Liability Release for all KMC sponsored activities Acknowledgment of Risk: While the above activities can be fun, I understand that they involve certain risks. I have carefully considered the risks involved and consent to my child’s participation in the above activities. I understand that participation in the above activities is entirely voluntary and participants, including my child, must abide by applicable rules and standards of conduct. I understand that the above activities may require my child or children to be transported by Kidron Mennonite Church’s staff or volunteers. Release from Liability: I release Kidron Mennonite Church, its staff, its volunteers, and other persons or organizations associated with the above activities from all claims arising out of my child’s participation in the above activities or transportation incident to such participation. Indemnification: Further, I agree to indemnify Kidron Mennonite Church, its staff, its volunteers, and any other persons or organizations associated with the above activities against any claims for injury, death, or property damage brought by or on behalf of my child as a result of participation in the above activities. * Please initial

Copy of Kidron Mennonite Church Youth Programs Participant Registration

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