Child's Name *

First Name

Last Name

Child's Birthdate *

MM

DD

YYYY

Primary Phone# *

(###)

###

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Alternate Phone#

(###)

###

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Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Emergency Phone# *

(###)

###

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Ok to post your child's unnamed photos on our website? *

Yes

No

to attend and participate in the activities at Cedarcroft Bible Chapel (CBC). I give my permission for CBC staff to administer basic first aid, if needed. In case of a medical emergency, every effort will be made to contact me. However, if I cannot be reached, I give my permission to the staff at CBC to secure the services of emergency personnel/licensed physicians to provide the necessary care, including anesthesia, surgery or hospitalization, if necessary, for my child’s well-being.

I understand that CBC and its staff are not held responsible for any monetary incurrence for medical treatment. I agree to hold harmless CBC and its staff of any liability. *

I understand that checking "Accept" constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Accept

Date *

MM

DD

YYYY