2024-2025 Northfield Community Church Kids Activity Registration

Parent/Guardian Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Medical Release *

As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician of the following minor(s) in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the number(s) listed below. The undersigned assumes the responsibility for any cost connected with such treatment and hereby releases Northfield Community Church from any liability therefore.

I DO Authorize

I DO NOT Authorize

Child's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Child's Name

First Name

Last Name

Birthdate

MM

DD

YYYY