Program Registration: After School Hangout at Solid Rock Baptist Church

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Please read and fill out this form if your child will be participating in the after school program at Solid Rock Baptist church on Wednesdays.

Email *

Child's Gender *

Child's Name (First, Last) *

Parent 1 Name (First, Last) *

Parent 1 Home Phone Number *

Parent 1 Cell Phone Number *

How may we contact Parent 1? *

Text

Call

All of the above

Parent 2 Name (First Last)

Parent 2 Email Address

Parent 2 Home Phone Number

Parent 2 Cell Phone Number

How may we contact Parent 2?

Text

Call

All of the above

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In the event of cancellation or emergency, which is best method of contact? Add any additional Emergency Contacts here. *

People who are authorized to pick up your child (include all). *

Address, City, State, Zip *

Child's Birth Date *

YYYY

Child's Grade Level *

What school does your child attend? *

East Elementary

Maple Ridge

Pendleton Elementary

Pendleton Middle School

List any special needs, medical conditions, or requests? *

What time will your child be picked up? *

5:45pm (no dinner included)

8:15 (free dinner included, students will stay for our Wednesday night youth programs)

List any food allergies. *

CONSENT AND RELEASE FORM

I, the undersigned parent or legal guardian, hereby consent to, herein referred to as my child, participating in After School Care, an event sponsored by Solid Rock Baptist Church, Pendleton, IN every Wednesday after school, 2021. I certify that my child is able to participate in the following activities: riding the bus from school to church building, games, dinner, services. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number(s) listed above. If I cannot be reached, I hereby authorize Solid Rock Baptist Church, to make emergency medical decisions for my child. If there are any activities I do not want my child to be involved in, I have listed them below. I understand and hereby agree to assume all of the risks which may be encountered on said activity, including activities preliminary and subsequent thereto. I do hereby agree to hold Solid Rock Baptist Church, Pendleton, IN and its volunteers and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which my child now has or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Indiana, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto, and the terms of this release are contractual and not a mere recital. *

By checking this box, I consent to the terms above.

Required

List any activities you do not want your child to be involved in. (Dinner services, games, etc.) *

Photography Consent: I give permission for my child to be videotaped or photographed. I understand that the images may be displayed in any church publications, church building, or website, *

Yes

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