2026-2027 FBC Breakout Registration form

PARENT/GUARDIAN INFORMATION

Parent #1 Name

Phone

This address will receive a confirmation email

Address

Parent #2 Name

Phone

Address

CHILD #1 INFORMATION

Name

Address (if different from parent/guardian)

Age

DOB

School Grade

Food or other allergies

CHILD #2 INFORMATION if applicable

Child #2

Address (if different from parent)

Age

DOB

School Grade

Food or other allergies

CHILD #3 INFORMATION if applicable

Child #3

Address (if different from parent)

Age

DOB

School Grade

Food or other allergies

EMERGENCY CONTACT INFORMATION

Emergency Contact #1

Phone

Emergency Contact #2

Phone

CHILD CUSTODY

If YES, child resides with whom? Yes No Not applicable

The following persons (first & last name) are allowed to pick up my child(ren):

PHOTO RELEASE

The following will allow FBCH to use photographs for publication, social media, and website purposes.

FBC KIDS QUEST PHOTO RELEASE

I, the above mentioned Parent/Guardian, hereby grant the First Baptist Church of Hiawatha permission to use my or my child(ren)'s likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the First Baptist Church of Hiawatha and will not be returned. I hereby irrevocably authorize the First Baptist Church of Hiawatha to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my or my child(ren)'s likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. I hereby hold harmless, release, and forever discharge the First Baptist Church of Hiawatha from all claims, demands, and causes of action which I, my child(ren), my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

YES NO

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW.

YES NO

PARENT/GUARDIAN SIGNATURE (Please type or sign full name. If signature is digital, it shall act as authorizing signature.)

Description

Please fill out this form and click submit.

2026-2027 FBC Breakout Registration form

Description

Please Fix the Following