KIDS Rock RegistrationLearn More
full name (required):
address (required):
city state zip (required):
home phone (required):
gender (required): -- select one -- male female
date of birth (required):
grade (required): -- select one -- kindergarten first grade second grade third grade fourth grade
emergency contact (required):
emergency contact # (required):
medical insurance co (required):
policy number (required):
allergies to medicine or other (required):
current medications (required):
date of last tetanus (required):
vaccinations to date (required): -- select one -- yes no
how did you hear about us: -- select one -- at RMCC website from a friend newspaper other
full name:
cell phone:
email address:
By signing below, as the parent or legal guardian, having legal custody of the above named child, I give permission for a licensed doctor, physician, or emergency treatment center, selected by the person in charge of any Red Mountain Community Church event, to administer the necessary attention and aid immediately to our child should he/she become injured or sick at the event scheduled for the Summer of 2008 and to do so without having to wait until I have been contacted. I furthermore understand that I will be held liable for the expense of that treatment. I consent to X-rays, examination, anesthetic, medical or surgical diagnosis, treatment, and hospital care. I understand the event leader will endeavor to reach us should the nature of the injury or illness warrant it. However, we will not hold any of the event personnel responsible if efforts to contact me are unsuccessful.
By signing below, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated with participation in the activity described above. Except for gross negligence on the part Red Mountain Community Church, the participant’s parent/guardian accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian) promises to hold harmless Red Mountain Community Church and its representatives for any injury related to the activity. If a dispute over the agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable arbitration process.
By signing below, I also authorize, in advance, the RMCC leaders to give my son/daughter Tylenol (or similar pain medication) if, in the opinion of the adult leaders of the activity, my child is in need of such over-the-counter medication.
pain medication (required): -- select one -- yes no
PHOTOGRAPHY RELEASE: By signing below, I hereby give Red Mountain Community Church the right to record photographs and video footage of my child(ren) and to use, re-use, publish and re-publish in whole, or in part for any purpose, including, but not limited to illustration, training or promotion. I hereby release and discharge Red Mountain Community Church from any and all claims, and demands arising out of or in conjunction with the use of the images.
photo release (required): -- select one -- yes no
By entering my name, email address and today's date in the fields below, I am in effect electronically signing this release.
email address (required):
today's date (required):