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Lititz Kids Alive Registration
Event Dates: February 5th - April 8th, 2020
Event Times: 6:00 - 7:15pm
Event Address: 44 E. Orange St. Lititz, PA
Contact us at 717.626.2175 or
amber@lititztrinity.org
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Email
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Your email
Contact Information
Child's Name
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Your answer
Grade
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Choose
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
School
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Your answer
Parent/Guardian
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Your answer
Parent/Guardian Phone #
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Your answer
Parent/Guardian Email
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Your answer
Emergency Contact
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Your answer
Emergency Contact Phone #
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Your answer
Child's Physician
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Your answer
Physician's Phone #
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Your answer
Physician's Address
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Your answer
Child's Allergies
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Your answer
Child's Meds
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Your answer
Permission for Emergency Medical Care:
By my signature on this form, I give permission to Lititz Kids Alive director/staff that in case of an emergency, and if I cannot be contacted, my child may be taken to the nearest hospital for treatment.
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No
Required
By my signature below in this form, I, the parent/legal guardian grant permission for my child to participate in Lititz Kids Alive programming. I do not hold Lititz Kids Alive staff or volunteers responsible for any injuries, sickness, or other medical concerns that happen during the time of programming.
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No
Required
I give my permission for Lititz Kids Alive to use my child's photo, video, and name in any article to be displayed in the church on or church media
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No
Required
Electronic Signature
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We ask that you physically sign the release form the first time your child attends LKA.
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