2021-22 BREAKOUT KIDS CLUB REGISTRATION FORM

The bus drives again! The first afternoon of Breakout Kids Club will be Wednesday, September 8th. Breakout will meet every Wednesday school is in session through April 2022.

PARENT/GUARDIAN INFORMATION

If completing by hand, please PRINT in all areas

PARENT/GUARDIAN NAME #1

PARENT/GUARDIAN #1 EMAIL

This address will receive a confirmation email

PARENT/GUARDIAN #1 CELL PHONE

PARENT/GUARDIAN #1 PHYSICAL ADDRESS

PARENT/GUARDIAN NAME #2

PARENT/GUARDIAN #2 EMAIL

PARENT/GUARDIAN #2 CELL PHONE

PARENT/GUARDIAN #2 PHYSICAL ADDRESS

MAILING ADDRESS (if different from physical)

EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT NAME

EMERGENCY CONTACT PHONE

EMERGENCY CONTACT #2 NAME

EMERGENCY CONTACT #2 PHONE

FAMILY DOCTOR

DOCTOR PHONE

INSURANCE CARRIER

POLICY NUMBER

CHILD #1's INFORMATION

CHILD'S NAME

BIRTHDATE

GRADE LEVEL

PRE-K KINDERGARTEN 1ST 2ND 3RD 4TH

GENDER

MALE FEMALE

KNOWN ALLERGIES (if none write "NONE")

ELEMENTARY SCHOOL TEACHER'S NAME

CHILD #2's INFORMATION (if applicable)

CHILD'S NAME

BIRTHDATE

GRADE LEVEL PRE-K KINDERGARTEN 1ST 2ND 3RD 4TH

GENDER MALE FEMALE

KNOWN ALLERGIES (if none write "NONE")

ELEMENTARY SCHOOL TEACHER'S NAME

CHILD #3's INFORMATION (if applicable)

CHILD'S NAME

BIRTHDATE

GRADE LEVEL PRE-K KINDERGARTEN 1ST 2ND 3RD 4TH

GENDER MALE FEMALE

KNOWN ALLERGIES (if none write "NONE")

ELEMENTARY SCHOOL TEACHER'S NAME

CHILD #4's INFORMATION (if applicable)

CHILD'S NAME

BIRTHDATE

GRADE LEVEL PRE-K KINDERGARTEN 1ST 2ND 3RD 4TH

GENDER MALE FEMALE

KNOWN ALLERGIES (if none write "NONE")

ELEMENTARY SCHOOL TEACHER'S NAME

CHILD #5's INFORMATION (if applicable)

CHILD'S NAME

BIRTHDATE

GRADE LEVEL PRE-K KINDERGARTEN 1ST 2ND 3RD 4TH

GENDER MALE FEMALE

KNOWN ALLERGIES (if none write "NONE")

ELEMENTARY SCHOOL TEACHER'S NAME

SPECIAL CONSIDERATIONS

CHILD CUSTODY

YES NO

IF "YES" TO CUSTODY, CHILD RESIDES WITH?

ADDRESS

ARE CUSTODY PAPERS ON FILE WITH FBC YES NO

THE FOLLOWING INDIVIDUALS ARE THE ONLY PEOPLE ALLOWED TO PICK UP MY CHILD FROM BREAKOUT

PHOTO AND BUS RELEASE

The following will allow your child(ren) to ride the Breakout Bus from the Elementary School to First Baptist Church in Hiawatha (FBCH). This will also allow FBCH to use photographs for publication and website purposes.

BREAKOUT BUS RELEASE

I, the above mentioned Parent/Guardian, hereby give permission for the above mentioned child(ren) to ride the Breakout Bus to First Baptist Church of Hiawatha on Wednesday afternoons. 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 DOES NOT APPLY

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 BUS AND 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.)

2021-22 BREAKOUT KIDS CLUB REGISTRATION FORM

Description

Please Fix the Following