Wednesday Night Live! Registration Form 2017-18 for Grades 3-5
 
Wednesday Night Live! Registration Form 2017-18 for Grades 3-5
Child's Last Name  * 
Child's First Name  * 
Boy or Girl (please make selection)  * 
Mailing Address (Street or PO Box)  * 
City  * 
State  * 
Zip Code  * 
Child's Phone  * 
Child's Birthdate (i.e. 00/00/0000)  * 
Child's Age at Time of Registration  * 
Child's Grade for school year 2017-18  * 
Parents' First & Last Name(s)  * 
Parents' Cell phone Number  * 
Phone number where parents can be reached during "Wednesday Night Live!"  * 
Church You Attend. If none, please write none.  * 
Secondary Emergency Name & Phone Number  * 
"Wednesday Night Live!" Registration  * 
Would you like to include an optional T-Shirt for $10.00?
T-Shirt Size
If you are unavailable in the event of an accident or emergency, do you authorize a church representative to make arrangements for your child to receive medical care?  * 
Does your child have any allergies? If none, write "none."  * 
Do you fully release & hold harmless TEMPLE BAPTIST CHURCH, its volunteers & staff from all liability for any accident, injury or death caused while in attendance at any activity?  * 
Do you grant Temple Baptist Church permission to electronically display your child's picture on our Facebook page?  * 
Do you attest that adequate insurance is in effect to cover your son or daughter while attending all "Wednesday Night Live!" activities?  * 
Do you authorize the physician named below to provide care and treatment for your child as deemed necessary in the event of an accident or medical emergency?  * 
Physician's Name & Phone Number  * 
Insurance Provider & Group/Health ID #  * 
Your Email Address  * 
Total $
 
 
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