Hope Community Church - Gilbertsville, PA

Parent/Guardian
First Name:
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Parent/Guardian
Last Name:
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Email Address:
Home Phone:
Cell Phone:
Address:
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City:
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State:

Zip Code:
All fields are required for each child. If no allergies simply enter "none".

Child #1 Name:
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#1 Age:
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#1 Grade in Sept 2010:
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#1 Special Needs / Allergies
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Child #2 Name:
#2 Age:
#2 Grade in Sept 2010:
#2 Special Needs / Allergies:

Child #3 Name:
#3 Age:
#3 Grade in Sept 2010:
#3 Special Needs / Allergies:

Add'l Children (Please enter Name, Age, Special Needs/Allergies, & Grade):

Church Affiliation

Emergency Contact Information
Contact Name:
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Home Phone:
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Cell Phone:

I give permission for my child to participate in this activity. In the event he/she is injured I waive and release all rights to any claim for damages against the sponsor or its representatives. I further agree that any claim or dispute arising from or related to this agreement shall be settled by mediation and if necessary legally binding arbitration in accordance with the Rules of the Institute for Christian Conciliation judgment upon an arbitration award may be entered in any court otherwise having jurisdiction.
For Pick-Up you will receive a tag with a code each night at registration. This tag is to be presented to your child's Discovery Leader in order to pick up your child at the appropriate location. If you are not the one picking up your child you will need to leave a note and identification will need to be shown in order to pick up the child.
T-shirts for the event are available for the cost of $5.00 Child(M, L) Adult(S, M, L, XL, XXL). Payment is necessary to receive t-shirt.
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