Kids Registration, Medical, & Travel Release Form

Date *

Child's Information

Name (First + Last) *

Birthday *

Age *

Address *

Phone *

School *

Church You Most Often Attend *

MPBC

OtherOther

Email Address *

Parents' Information

Father's Name (First + Last) *

Father's Phone *

Father's Work Phone

Mother's Name (First + Last) *

Mother's Phone *

Mother's Work Phone

Medical Release Information

Allergies *

If you choose one, a text box for more information will appear.

Previous operations or serious illnesses *

Is your child currently taking any medication? *

Yes

If so, what?If so, what?

None

Special Diet (name) *

In case of emergency (Name & Number) *

Family Physician *

Physician's Phone *

Family Insurance Co. *

Insurance Phone *

Medical & Travel Release

"My permission is granted for any Mount Pleasant Baptist Church staff member or sponsor in charge of the trip to obtain medical attention in case of sickness or injury for child list above.

"I/We, the undersigned, do hereby release, remise and forever discharge all sponsors and Mount Pleasant Baptist Church, Colonial Heights, Virginia, from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating in this event. I also agree to pick up my student or reimburse MPBC for the cost of sending my student home in the event that he/she commits any infraction of the rules, puts their fellow participants in danger, or exhibits a disruptive attitude."

Digital signature disclaimer *

Yes, I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

No, I will sign in person.

Digital Sigature