Child's Name *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone Number of Parent/Guardian

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Number

(###)

###

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Medical Release: I authorize Capitol Hill Assembly of God to administer medical care should it become necessary, understanding that I will be contacted immediately in such an event. In the event that someone cannot be reached, I hereby authorize a church reprsentative to secure proper treatment necessary for my child named above. I accept responsibility for payment of expenses incurred as a result of medical treatment.

By checking this box, you consent to our Medical Release

Liability Release: I hereby release Capitol Hill Assembly of God and all its participants from any liability or damage to or loss of personal property, sickness or injury from whatever source which might occur while attending this event.

By checking this box, you consent to our Liability Release

Media release: By attending this event I give Capitol Hill Assembly of God permission to use my child's image on church Facebook page, church website, video and other media, knowing that all media is used form promotional purposes only.

By checking this box, you consent to our Media Release