KCC Kids Wednesday Registration

Family Information

Parents/Guardians Name

This address will receive a confirmation email

Home Phone

Cell Phone

Address

Child Information

Child 1 First Name

Child 1 Last Name

Child 1 Birthday

Child 1 Gender

Male Female

Allergies and/or special medical conditions

Child 2 First Name

Child 2 Last Name

Child 2 Birthday

Child 2 Gender Male Female

Allergies and/or special medical conditions

Child 3 First Name

Child 3 Last Name

Child 3 Birthday

Child 3 Gender Male Female

Allergies and/or special medical conditions

Child 4 First Name

Child 4 Last Name

Child 4 Birthday

Child 4 Gender Male Female

Emergency Contact Information

Must list a minimum of one contact. Please list an adult OTHER than parent/guardian.

Emergency Contact 1 First Name

Emergency Contact 1 Last Name

Emergency Contact 1 Phone

Emergency Contact 2 First Name

Emergency Contact 2 Last Name

Emergency Contact 2 Phone

Medical and Media Release

I consent to the use of any visual or audio recording that may be taken during participation in KCC Kids of above named persons.

Please list any media restrictions

I acknowledge that participation in the program listed on the previous page involves risk to the participant (and to the participant's parents or guardians, if the participant is a minor), and may result in various types of injury including but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage.

In consideration for the opportunity to participate in the program listed on previous page (KCC Kids Wednesday night), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risk of injury associated with the participation and transportation to and from the program. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the program, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers or any other representatives (collectively referred to as the Program Sponsor). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless that Program Sponsor for any injury arising directly or indirectly out of the described program or transportation to and from the activity, whether such injury arises out of the negligence of the Program Sponsor, the participant or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the Program Sponsor cannot agree on such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

Parent/Guardian Signature

I Agree I do not Agree

Date Signed

KCC Kids Wednesday Registration

Description

Please Fix the Following