Youth Choir 2011 Mission Tour Registration

2011 Youth Choir Mission Tour (dates TBA)

Initial deposit due: TBA

If you have any questions contact Bryan Black at bryanblack@mariettafumc.org

ONE FORM PER CHILD

Child’s name: male female

Social Security Number:

Birthdate: Age as of 9/1/10

Grade:

School:

Parent/Guardian:

Street Address:

City/State/Zip:

Home phone: Cell/Work:

Parent email (IMPORTANT!):

Allergies/medical information/special diet or other concerns:

My child is covered by health/accident insurance Yes No

Insurance company and ID/Member #

Emergency contact Name:

Emergency Contact Phone:

Emergency Contact Name:

Emergency Contact Phone:

Names of persons who may pick up this child other than parent/guardian:

Please list any custody arrangements that we need to be aware of:

This is to certify that my permission is granted for my child to participate in organized sponsored activities whether on the church campus or away. Therefore, I acknowledge unless gross negligence is involved, First United Methodist Church or First United Methodist Church employees cannot be held responsible for medical or hospital costs resulting from injuries that might occur by participating in First United Methodist Church program sponsored activities, or in transportation to or from the place where the activities are conducted. Children must be insured to participate in Marietta First United Methodist Church Programs.

I have read or have had read to me the foregoing in its entirety and by placing my signature below do declare that I understand that any cost or injury resulting from participation in church sponsored activities is my responsibility.

I give permission for my child’s photograph or video image to be used on promotional or informational materials, press media, and possible publication on the World Wide Web through he church’s web page for positive public relation purposes.

Yes No

Electronically sign this form by entering your initials here: