CORNERSTONE CHILDREN / YOUTH PROGRAM REGISTRATION FORM Today's Date MM slash DD slash YYYY Parent/Guardian InformationMother/Legal Guardian NameMother's Email Address Mother's Phone NumberFather/Legal Guardian NameFather's Email Address* Father's Phone NumberChild lives with: Both Parents Mother Father If the person who regularly brings the child is different than above, please list *optional List adults (18 or older) that are allowed to pick up your child *optional Child InformationHow many children will be attending?*OneTwoThreeFourChild #1 NameChild 1 Date of Birth & Current Age Child 1 Gender Male Female Child 1 Grade and School Attending Child 1 Please list any medications/allergies/medical conditions/concerns we should know about Child #2 NameChild 2 Date of Birth & Current Age Child 2 Gender Male Female Child 2 Grade and School Attending Child 2 Please list any medications/allergies/medical conditions/concerns we should know about Child #3 NameChild 3 Date of Birth & Current Age Child 3 Gender Male Female Child 3 Grade and School Attending Child 3 Please list any medications/allergies/medical conditions/concerns we should know about Child #4 NameChild 4 Date of Birth & Current Age Child 4 Gender Male Female Child 4 Grade and School Attending Child 4 Please list any medications/allergies/medical conditions/concerns we should know about Additional InformationEmergency Contact (other than parent) Relationship & Phone Number Is Cornerstone your home church? Yes No If no, what church do you attend? *optional Family Doctor & Phone number ReleasesThank you for completing this form. Please review following releases that will need to be signed when you drop your child off after submitting this form. EMERGENCY TREATMENT RELEASE: THE UNDERSIGNED PARENT(S)/GUARDIAN(S) HAVING LEGAL CUSTODY OR CONTROL OF MINOR(S), GIVE PERMISSION FOR THEIR CHILD(REN) TO PARTICIPATE IN CORNERSTONE CHURCH'S CHILDREN/YOUTH PROGRAMS. I GIVE CORNERSTONE CHURCH AND ITS AGENTS PERMISSION TO SEEK EMERGENCY TREATMENT AND HOSPITAL SERVICES THAT MAY BE RENDERED TO SAID MINOR(S) IF DEEMED NECESSARY AT MY EXPENSE. I RELEASE CORNERSTONE CHURCH AND ALL ITS AGENTS FROM ANY AND ALL LIABILITY CONCERNING MY CHILD(REN). PHOTO RELEASE: CORNERSTONE CHURCH OFTEN TAKES PHOTOS OF EVENTS AND ACTIVITIES AND WE OFTEN POST THESE IMAGES IN PROMOTIONAL AND OTHER MEDIA. IF YOU DO NOT WANT YOUR CHILD(REN) TO BE PHOTOGRAPHED, PLEASE MARK NO ON THE SPACE PROVIDED. PLEASE NOTE THAT IF YOU SELECT NO, WE MAY HAVE TO ASK YOUR CHILD TO NOT BE INCLUDED IN ANY PHOTOGRAPHY BEING DONE. PLEASE EXPLAIN THIS IN ADVANCE TO YOUR CHILD. IF YOU DO NOT MARK NO, THE UNDERSIGNED PARTY GIVES PERMISSION FOR CORNERSTONE CHURCH TO PHOTOGRAPH YOUR CHILD(REN). WAIVER OF CLAIMS AND INDEMNITY ANNUAL AGREEMENT: I AM AWARE OF THE NATURE OF THE ACTIVITIES IN WHICH MY CHILD(REN) IS PARTICIPATING IN AT CORNERSTONE'S CHILDREN/YOUTH PROGRAMS (INCLUDING BUT NOT LIMITED TO SUNDAY PROGRAMS, WEDNESDAY PROGRAMS, PARENT'S NIGHT OUT) AND UNDERSTAND THAT ACCIDENTS AND INJURIES MAY OCCUR AS A RESULT OF PARTICIPATION IN SAID ACTIVITIES. I HEREBY WAIVE ANY CLAIMS AGAINST, AND AGREE TO RELEASE AND DISCHARGE IN ADVANCE CORNERSTONE CHURCH, ITS BOARD, MEMBERS, VOLUNTEERS AND EMPLOYEES FROM ANY AND ALL LIABILITY FOR PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE WHICH ME OR MY CHILD MAY HAVE, OR WHICH MAY HEREAFTER ACCRUE TO ME OR MY CHILD AS A RESULT OF SUCH PARTICIPATION, EVEN THOUGH THAT LIABILITY MAY ARISE OUT OF CORNERSTONE OR ITS EMPLOYEE'S NEGLIGENCE OR CARELESSNESS. I FURTHER AGREE THAT THIS WAIVER, RELEASE AND ASSUMPTION OF RISKS IS TO BE BINDING UPON MY AND MY CHILD'S HEIRS AND ASSIGNS. I ALSO HEREBY AGREE TO INDEMNIFY AND HOLD THE ENTITY AND PERSONS MENTIONED ABOVE HARMLESS AGAINST ALL CLAIMS, DAMAGES, LOSSES AND EXPENSES, INCLUDING ATTORNEY'S FEES, WHICH THEY MAY INCUR AS A RESULT OF MY CHILD'S PARTICIPATION IN THE PROGRAM(S). I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, AND A CONTRACT BETWEEN CORNERSTONE CHURCH AND ME, AND I SIGN IT OF MY FREE WILL.EmailThis field is for validation purposes and should be left unchanged. Δ
