Event Registration

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Element (5th & 6th Grade) on Wednesday, September 20, 2017 @ 7:00 PM

40.00
1No Additional Charge 
1No Additional Charge 
*Gender:
*Birth Date:
*School Child Attends:
*Church Child Attends (if applicable):
PARENT/GUARDIAN INFORMATION:
Full Name of Parent/Legal Guardian:
*Person(s) Child Resides With:
*Cell Phone Number:
*Cell Number is for::
*Do you want to receive a text messages about theElement?:
*Email Address:
*Email Address is for:
MEDICAL INFORMATION:
*Insurance Carrier:
*Insurance Policy Number:
*Health Issues or Allergies:
Permission for child to receive over-the-counter medications (such as Tylenol, Pepto-Bismol, Cough Meds) when needed.:
*Permission for over-the-counter meds:
EMERGENCY INFORMATION:
*First Name:
*Last Name:
*Contact Phone:
*Phone is for:
CONSENT/RELEASE FORM:
The pre-teen above has my consent to attend KidVenture theElement 2017/2018, sponsored by Yorba Linda Friends Church and to participate in the activities involved in this event. I understand and agree that neither YLFC, nor its trustees, elders, representatives, employees, or agents may be held liable in any way for an occurrence in connection with involvement in KidVenture theElement 2017/2018 activities, which may result in injury, harm, or other damages to named child. In the event of a medical or dental emergency I authorize a representative of YLFC pursuant to the provisions of California family code 6910, to consent to medical or dental care or both for the named child. I give my permission to the attending physician to hospitalize, secure proper treatment, and to order injections, anesthesia or surgery for named child. I understand that all billings for services rendered will be sent to the parent/Legal Guardian and who is responsible for the complete payment. I understand that insurance coverage is the responsibility of each family, and that church coverage begins where our personal health and accident policies terminate. Regarding transportation, I am aware that named child will be transported to and from the event in a church rental or private vehicle. I also give permission to photograph and videotape named child for future promotional material, including Yorba Linda Friends Church website postings, without expectation of compensation. Activities include, but are not limited to inflatable equipment. I voluntarily allow my child to participate in the activities and assume the risks of injury or harm that could result from participation. On my own behalf and that of my personal representative and heir, I hereby release Yorba Linda Friends Church its officers, employees and agents from all liability for any injury or harm to my child from participating in the said activities. I understand that a photocopy, facsimile, or computer version of this document shall be treated as the original.:
*Consent/Release Agreement:
EVENT INFORMATION:
*T-Shirt Size (included in Registration fee):
Name of Buddy:
Name of a Leader:
*Serve Team Preference - First Choice:
*2nd Choice:
PARENT REQUEST:
(we are looking for parents who would want to help support the pre-teen ministry by serving in the following ways):
I would be willing to serve as: (please, check yes, if possible to one or more):
*A driver for an event:
*Event Volunteer:
*Shopper (we will reimburse your expenses):
*Provide Peanut free snacks:
*I have stuff to lend (home, car, boat, pool, truck, towing vehicle, etc:
*Office help:
*Event or party planning:
*Provide gift cards to Walmart/Amazon/Costco:
If yes, please describe:
*Cooking or baking:
*I would be willing to cook a meal one (1) time per month for small group leaders (10-12 people):