Registration Form for Tumbling Shoals Baptist Church summer program - Totally Terrific Thursday.
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TSBC TRIPLE “T” REGISTRATION FORM
Every Thursday, June 9 – July 14
10:00 AM to 12:00 PM
For Children 4 years old up to finished 5 th Grade
PARTICIPANT INFORMATION
PARTICIPANT'S NAME
DATE OF BIRTH
DATE OF REGISTRATION
ADDRESS STREET
CITY
STATE
LAST GRADE COMPLETED
ZIP
PERMISSION TO BE PHOTOGRAPHED:
YES
NO
PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN’S NAME
HOME PHONE
CELL PHONE
MOM’S PLACE OF EMPLOYMENT
EMPLOYMENT ADDRESS
WORK PHONE
DAD’S PLACE OF EMPLOYMENT
EMPLOYMENT ADDRESS
WORK PHONE
IF PARENT/GUARDIAN CANNOT BE REACHED
PLEASE CONTACT:
PHONE NUMBER
WHO IS AUTHORIZED TO TRANSPORT PARTICIPANT
PHONE NUMBER
RELATIONSHIP TO
PARTICIPANT:
MEDICAL INFORMATION
PLEASE LIST ANY ALLERGIES (INCLUDING FOOD ALLERGIES) PHYSICAL CONDITION, DEFECTS, OR MEDICAL
CONDITIONS THAT WOULD LIMIT PARTICIPANT FROM PARTICIPATING:
MEDICAL/WAIVER/RELEASE OF RESPONSIBILITY
I ACKNOWLEDGE, UNDERSTAND, AND ASSUME ALL RISKS INVOLVED IN ANY ACTIVITIES ON THE PREMISES OF
TUMBLING SHOALS BAPTIST CHURCH. I FURTHER AGREE TO HOLD HARMLESS TUMBLING SHOALS BAPTIST
CHURCH, THE VOLUNTEERS OR STAFF TEACHERS, FROM ANY AND ALL CLAIMS, SUITS, LOSSES,
OR DAMAGES OF ANY NATURE WHAT SO EVER, INCLUDING BUT NOT LIMITED TO, SUCH CLAIMS THAT MAY
RESULT FROM MY CHILD'S INJURY OR DEATH, WHETHER IT BE ACCIDENTAL AS A RESULT OF NEGLIGANCE OR
OTHERWISE, DURING OR ARISING IN ANY WAY FROM SUMMER PROGRAM ACTIVITIES.
I HEREBY GRANTPERMISSION TO LICENSED HOSPITAL AND/OR STAFF MEMBERS TO ADMINISTER IMMEDIATE
MEDICAL TREATMENT AS DEEMED NECESSARY TO MY CHILD SHOULD HE/SHE BE INJURED DURING ANY
EVENT HE/SHE LEFT IN THE CARE OF TUMBLING SHOALS BAPTIST CHURCH VOLUNTEERS OR STAFF.
FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF EXPENSES INCURRED RELATING TO MY
CHILD'S MEDICAL TREATMENT.
PARENT/GUARDIAN SIGNATURE