Kids Town Registration

General Information

Child's First Name

Child's Last Name

Child's Age

Child's Gender Male Female

Year in School

Birthdate

Parent/Guardian Name

This address will receive a confirmation email

Phone

Preferred method of contact

Text Phone Call Either is fine

Address

Parent/Guardian Name (Second Parent/guardian information is optional)

Phone

If unable to reach parent or guardian, please give us an alternate emergency contact (name and phone number)

Medical Insurance Information (Please include Policy #)

Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which staff should be aware, and what, if any, action of protection is required on account thereof. Submit this notification either in writing, or email it to KidsTownRCOA@gmail.com, (please put your child's name in the subject line). Include names of medications and dosages that must be taken.

Does your child have allergies to:

Pollens Medications Food Insect Bites Other None

If child has specific allergy, please explain:

Date of last tetanus shot:

Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:

Asthma Diabetes Epilepsy/Seizure Disorder Frequent Upset Stomach Heart Trouble Physical Handicap Other None

Additional Comments

Does your child wear:

Please list any major illnesses the child experienced during the last year. Please include any additional comments, and if there are any restrictions to the child's activities.

Please list any medications your child is currently taking and that may be needed in a Kids Town event or trip:

Please List any special needs your child has and what our response can or should be:

Please provide any other information that would help us care for your child:

The student named above has my consent to participate in the Kid's Town Ministry of Relevant Church of Allentown and any organization that is utilized by Relevant Church of Allentown in a children's ministry.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the church and its staff of any liability against personal losses of named child.

I/We, the undersigned, have legal custody of the student named above, a minor, and have given my/our consent for him/her to attend the activities of Relevant Church of Allentown Children's Ministry. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/We hereby release the church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/We agree to hold such personnel free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named abovew. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the children's ministries staff member.

Electronic Signature (First and Last Name)

Kids Town Registration

Description

Please Fix the Following