Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

Please list a phone number in which we could reach you on Wednesday evening if needed.

(###)

###

####

Emergency Contact Name *

Please list another contact, in case we are unable to reach you.

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Health Policy for KIDZONE *

While it is impossible to guarantee that anyone, at any time, is completely safe from the COVID-19 virus or any other virus or illness, KIDZONE and Antioch Alliance church are doing all they can to provide a safe environment. We will be checking everyone’s temperature with the non-touch infrared thermometers. Kids or staff with a temp of 100 degrees F or more will not be able to attend that evening. We are instituting social distancing and cleaning policies and changing our pick up procedure at the close of the evening. And we recommend the wearing of masks. (Masks are optional, unless currently required by state orders.) If your child has a fever, cough, vomiting, diarrhea, communicable disease, rash, etc. or if they have missed school because of illness please keep your child home from church sponsored events until the symptoms have been resolved for 24 hours. EVERY CHILD MUST HAVE A COMPLETED REGISTRATION FOR ON FILE before attending KIDZONE.

I have read and accept the Health Policy.

Emergency Treatment Permission *

In case of a medical emergency, we will call 911 and then the parents. In this case emergency and hospital policy requires parental permission before treatment. I hereby give my permission to Antioch Alliance Church to secure proper medical treatment for any child listed on the front of this form.

I have read this policy and give my permission for Emergency Treatment for my child/children.

Notice / Release of Liability / Personal Items *

We do not recommend that kids bring cell phones, iPods, Notebooks, Kindles, etc. to the church, we cannot assume responsibility for these personal items. In the event that you prefer to permit your child(ren) to carry these items to the church, please be aware that this is yours and your child's personal responsibility. We will ask the children to put all these items away in order to not disrupt their crews. If a child is non-compliant, we will contact the parent and request that you come to the office to pick up the personal item. Please sign below to indicate that you have read this notice and acknowledge that you assume responsibility for personal items and Antioch Alliance Church is not responsible for personal items brought to the church and that you / your child understands that the items are not to be in use during KIDZONE time.

I have read and accept the Release of Liability Policy.

Photograph/Social Media Recordings *

Kids love to have their pictures taken. And we often do take pictures of clubs, crews, regular meetings, special events, etc. May we have permission to include your child when we take pictures/record video.

Yes, my child(ren) may be included in photographs/videos.

No, do not include my child(ren) in photographs/videos.

Website Images *

Sometimes we like to post some of our club pictures/video on the church website. Again, may we have your permission to include your child.

Yes, my child may appear on the church website.

No, do not include my child in images/videos on the church website.

Transportation - Release of Liability

THIS IS REQUIRED FOR ANYONE THAT IS UTILIZING CHURCH-PROVIDED TRANSPORTATION. We (I) on behalf of our (my) child, assume all risk of personal injury, sickness, death, damage, and expense as a result of our child's participation in CHURCH ARRANGED TRANPSORTATION, VAN OR PRIVATE CAR, provided such are not created by negligent, willful, or intentional acts of Church staff and/or adult volunteer staff. We (I) further agree to indemnify and promptly reimburse the Church, its Elders, Deacons, employees and/or agents for any loss of liability, including related expenses, sustained by the Church as the result of the negligent, willful, or intentional acts of our (my) child. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

I have read the Transportation Policy, accept it's conditions and give my child(ren) permission to be transported to and from Antioch Alliance Church.