OLD WOW Summer Event Registration 2014

Please complete a form for each child attending

For children Kindergarten through 5th grade

* Indicates required field

Child's Name *

First

Last

Child's Date of Birth (mm/dd/yy) *

Last Grade Completed *

Allergies/Restrictions *

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Home Phone *

Parent/Guardian Cell Phone *

Parent/Guardian Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Please check the events your child will attend: *

7/9 Paint A Canvas - No Charge 7/16 Movie Day - $7.00 7/30 Bowling - $8.00

By checking the box below, you are authorizing Zachary United Methodist Church to use photographs of your child/children for promotional use:

Photo Authorization *

I agree

By checking the box below you agree that in the event of an illness or accident you authorize Zachary United Methodist Church to consent to any diagnosis, examination, treatment or hospital care for your child which is deemed advisable by and is rendered under the supervision of a physician. You hereby release Zachary United Methodist Church and its agents from responsibility in the case of an accident or illness in connection with any authorized church activities.

Authorization of Treatment of a Minor *

I agree

Submit