Children's Garden Club Registration

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Email *

Child's Name: *

Child's Birth Date: *

YYYY

Age: *

School:

Grade:

Parent/Guardian Name: *

Address:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Who will pick up your child (name & phone number)? *

Please tell us if there are any medical conditions we should be aware of (food allergies?):

Backup emergency contacts:

I hereby release the Executive Directors and all employees of Marydell Faith & Life Center from all claims of liability for any damages or injuries that may be sustained while my child is in the Marydell Faith & Life Center Program. *

Yes

During our programs we may take photos/videos or be photographed by the press or television. I hereby give permission for my child(ren)’s image to be used in connection with publicity, educational materials, or publications related to Marydell Faith & Life Center. I give permission for my child(ren)’s image to be used as stated above. *

Yes

Signature of Parent/Guardian (type full name): *

Date: *

YYYY

Send me a copy of my responses.

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