C3 Kids Waiver & Sunday Registration • C3 Church

Family Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Mobile Number *

Email *

Child(s) Information

Children's Last Name *

Child 1 First Name *

Child 1 Allergies/Special Needs

Date of Birth *

School Grade *

Child 2 First Name

Child 2 Allergies/Special Needs

Date of Birth

Child 2 School Grade

Child 3 First Name

Child 3 Allergies/Special Needs

Date of Birth

Child 3 School Grade

Child 4 First Name

Child 4 Allergies/Special Needs

Date of Birth

Child 4 School Grade

Release of Liability:

By consenting to this Release Form, I expressly warrant that the child/children named here is/are capable of withstanding both the physical and mental demands of the planned activities. I also expressly assume all risks of the child whether such risks are known or unknown to me at this time. I further release C3 Church and its ministers, leaders, employees and volunteers from any claim that my child may have against them as a result of an injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against C3 Church or its ministers, leaders, employees, or volunteers.

Please state whether or not your consent to the release of liability for your child. *

Yes

First Aid & Emergency Medical Treatment:

I do hereby give permission for agents of C3 Church to seek and secure any needed medical attention or treatment for my child including hospitalization. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment.

Please state whether or not you consent to the First Aid & Emergency Medical Treatment of your child. *

Yes

Media Release

On occasion, C3 Church takes photographs or makes audio/visual recording of children involved in church activities. Such photographs and audio/visual recording may be used in C3 church's publications, social media or website. I consent to the use of such audio/visual recording of the child/children named here to be used, distributed, or displayed, as the directors of the church see fit.

Photography Consent *

Yes

Date Signed *