Truth Trackers Registration Form

Parent/Guardian's Information

Parent/Guardian 1

Relationship (Mother, Father, Grandmother, etc)

Physical Address

Mailing Address (If different than above)

Primary Phone # (Please also specify type Home, Cell, Work)

Secondary Phone #

Other Phone #

This address will receive a confirmation email

Parent/Guardian 2

First Name

Last Name

Relationship

Physical Address

Mailing Address (If different than above)

Primary Phone # (Please also specify type Home, Cell, Work)

Secondary Phone #

Other Phone #

Email-2

This address will receive a confirmation email

Parent/Guardian 3

First Name

Last Name

Relationship

Physical Address

Mailing Address (If different than above)

Primary Phone # (Please also specify type Home, Cell, Work)

Secondary Phone #

Other Phone #

Email-3

Child 1 Information

First Name

Last Name

Birthday DD/MM/YYYY

Gender

Select Truth Trackers Program Group

School

Medical and Allergy Information - List Allergies & Medications (enter None if not applicable)

Current Immunizations

Yes No

Child 2 Information

First Name

Last Name

Birthday DD/MM/YYYY

Gender

Select Truth Trackers Program Group

School

Medical and Allergy Information - List Allergies & Medications (enter None if not applicable)

Current Immunizations Yes No

Child 3 Information

First Name

Last Name

Birthday DD/MM/YYYY

Gender

Grade

School

Select Truth Trackers Program Group

Medical and Allergy Information - List Allergies & Medications (enter None if not applicable)

Current Immunizations Yes No

Child 4 Information

Last Name

First Name

Birthday MM/DD/YYYY

Gender

Grade

Select Truth Trackers Program Group

Medical and Allergy Information - List Allergies & Medications (enter None if not applicable)

Current Immunizations Yes No

Authorized Adults, 18 and older, to pick up my children from Truth Trackers at Pionner Bible Church - List all Names and relationship and phone numbers of authorized people

Release and Consent

By checking yes, I acknowledge that I have read and understood the information on this form and I give consent to participate in the Pioneer Bible Church electronic registration.

1) Release of liability: I, for myself, my minor child and for the child's other parent and/or guardian, hereby release, waive, discharge, and covenant not to sue Pioneer Bible Church and it's officers, director, employees, agents, volunteers, heirs and assigns of and from all liability, loss, claims, demands, possible causes of action, court costs, attorney's fees and other expenses arising from any lawsuit that may otherwise occur from any loss or damage or injury to my child's person or property in any way resulting from or connected with my child's attendance at Pioneer Bible Church activities, including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections or the negligence of other persons. By checking yes, you give your consent to release of liability.

Yes, I agree No, I don't agree

2) Photo Release: I give permission for my child’s photo, which may be taken during activities, to appear on the church website www.pioneerbiblechurch.org or church administered Facebook page or to be used for publicity or display purposes. By checking yes, you are agreeing to a photo release.

Yes, I agree No, I don't agree

3) Consent to Medical Treatment: In the event my child becomes ill or injured, I give permission for a representative of Pioneer Bible Church to take whatever steps are reasonably necessary to render emergency first aid to my child. I also consent to such emergency medical treatment as may be reasonably necessary to insure the health and welfare of my child including, but not limited to, x-rays, anesthetic, medical or surgical diagnosis and treatment, hospital care and administration of drugs or medicine under the care of a licensed physician and/or surgeon. By checking yes, you are agreeing to medical treatment.

Yes, I agree No, I don't agree

4) Truth Trackers Contact Permission Authorization: Occasionally your child’s handbook leader would like to contact you and your child to see how they are enjoying the club, and if they need any help in completing their handbooks. Your child’s leader would also like to send written correspondence such as “Get Well” cards and a “Birthday Card.” By checking yes, you are giving your child’s leader written permission as the legal parent/guardian to contact you and your child, by written communication and by telephone to discuss club activities.

Yes, I agree No, I don't agree

Date:

Payment Information

Registration price includes Truth Trackers program, Shirt and Awards. Books are sold separately, if your child already has a book, you do not need to order a book.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Truth Trackers Registration Form

Description

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