Delta Club Registration Form
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Child's Name (First, Last) *
Child's Birthdate *
MM
/
DD
/
YYYY
Child's Age
Child's T-shirt size  *
Child's Grade *
Child's  Street Address *
City, State, Zip *
Home Phone # *
Parent/Guardian *
Cell Phone # *
Parent/Guardian E-mail *
Emergency Contact Name *
Emergency Contact Phone # *
Allegies *
Home Church *
I hereby authorize adult volunteers of Windborn Church of Rio Vista, CA, as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic, facility or hospital. *
Required
I further release from any liability. Windborn Church of Rio Vista, CA, and any of it’s ministries or leaders in the event of an accident during Delta Club and/or en-route, during and/or returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. *
Required
Do you give permission for images of your child, captured during Delta Club events through video or photo, to be used solely for the purposes of Windborn Church promotional material and publications? *
Mark as your signature *
Required
Health Insurance Company *
Policy or Group Number *
Doctor’s Name
Doctor’s Phone Number *
Dentist’s Name
Dentist’s Phone Number
Submit
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