Summerama KIDS form — Journey Church

CHILD SIGN UP

KIDS SUMMERAMA Journey 2023 “Wild Life”

August, Monday 1st through Friday 4th, 6:00pm - 8:00pm

8500 Memorial Dr. Plain City, OH 43064

Child's Name

First Name

Last Name

Child's Age

Last school grade completed:

Parent (s)/Guardian (s) Name

First Name

Last Name

Relationship to Child

Allergies/medications/medical problems?

(Optional) Please place this child with (list only one child’s name):

NOTE: If registering multiple children in the same family, all with the same guardian, the guardian information below is only required one time. However, the medical release is required for each child.

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you attend Journey?

If No, would you like more information about Journey?

How did you hear about Journey's KIDS SUMMERAMA?

List name of anyone besides parent/guardian listed above who has permission to pick up your child(ren):

Name/Phone number:

ALL INFORMATION REQUIRED Minor Participation Authorization and Consent to Emergency Medical Treatment (with photo consent) I, the undersigned, certify that I am the parent or legal guardian of:

I hereby give my consent to have my minor child participate in the following activity of Journey Church KIDS SUMMERAMA (hereafter “the activity”) on August 01, 02, 03, 04, 2023. I recognize that there are risks involved in participating in this activity and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in this activity. To the fullest extent permitted by law, I release Journey Church, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Journey Church, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity. Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x‐ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage. I also hereby give my consent that any and all photographs and/or videos of the minor child are the sole property of Journey Church and may be used in printed material, videos and/or on the church website.

Signature:

Signed on

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