The Reach - Children's Church Registration Form - First Time
Date: 04/14/24 *
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PARENT'S  INFORMATION
Mother
Victoria Witcher *
Victoria_witcher@yahoo.com *
403 Mt Olive drive Greensboro NC 27406 *
Parent(s) Mailing Address (City, State , Zip) 120 Clancy st. Apt C Salisbury NC 28147 *
3368978139 *
CHILD'S INFORMATION
Cayden Murphy  *
02/10/2012
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12
Child #1 - Grade 6th
Hayden Murohyy
02/10/2012
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12
Child #2 - Grade 6th
Child #3 Full Name
Child #3 - Date of Birth
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Child #3 - Age
Child #3 - Grade
AUTHORIZED PEOPLE TO PICK UP MY CHILD:  Hope Hart
(Child can be picked up no later than 1pm or all will return to main campus together.)
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MEDICAL HISTORY shellfish allergy
Are ANY of your children taking medications? No *
Required
If "yes" to the above question, please list all meds and reason for medication.
Please list ANY medical considerations that we need to be aware of for ANY children:
Emergency Contact Information: 
(Please list name, phone number and relation to child.  We will make every effort to contact parent first in case of emergency.) Hope Hart 9723488093
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Consent to treat and release of liability:
In consideration for being accepted by The Reach Church for participation in our children’s program, we (I), being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 18 years of age or older) do hereby release, forever discharge and agree to hold harmless The Reach Church and the directors, staff and volunteers thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described activity. 

Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify said organization, its directors, employees and agents, for any liability sustained by said organization as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. We (I) are the parents(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him or her to participate fully in our children’s program, and the activities done there, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.   
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Required
Authorized by: (The name listed below will be accepted as agreement of the above statements.) 
Marketing disclaimer and agreement: 
By checking this box, I understand that photos of my child may be taken while attending services and/or children's church for display at ministry events, on any of our social media platforms and/or in printed materials as determined by church staff.  No form of payment will be issued, at any time to the child, parent or authorized adult on behalf of the child.
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