St. Paul's Moravian Church :: Kid's Club Registration

Online Registration For St. Paul's Kid's Club

If your child has previously attended Kid's Club, you do not need to complete this form.

Please respond to the email if they will be attending.

Child First Name *
Child Last Name *
Age *
Date of Birth *
Parent's Name *
Other Contact
Street Address *
City State Zip *
Home Phone Number *
Parents' Cell Phone Number *
Parents' Email Address *
Religious/Church Affliation *
Name of Person(s) Other than Parents authorized to pick up child *
CONTACT FOR EMERGENCY *
Emergency Phone Number *
Are childhood shots up to date? *	Yes No
List any Unusual Health Conditions: (e.g., allergies to food, shots, etc.)
My Electronic Signature confirms that I have read the St. Paul's Moravian Church liability statement below: (First and Last Name) *
*	I understand this is a legal representation of my signature
Please type the letters and numbers shown in the image.
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Liability Statement

Parents – Please read and sign above, acknowledging the following statement:

I hereby agree to allow my child to participate in the programs and activities of Kid’s Club. I do hereby release and hold harmless St. Paul’s Moravian Church and its representatives from any and all liabilities arising from any injuries that might occur during the supervised program and activities. Further I give permission for Medical Personnel to administer First Aid and/or medical treatment in case of emergency and to refer the patient to a local clinic or hospital for treatment, if necessary.