Pine Knolls Family Ministry

2020-2021 Registration & Release Form

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Thank You, we have received your form.
    September 01, 2020 - 2021
    @12:00 - 12:00 AM
    Attendee
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  • Parent/Guardian Information

    Please complete the following information for at least one parent/guardian.


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  • Would you like to add information for another Guardian?

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  • The following people may drop off or pick up my child(ren):

  • Important or sensitive household information (including people who MAY NOT pick your child up):

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  • Waiver of Liability Statement

    I, the parent / legal guardian of THE ABOVE NAMED CHILD(REN) understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to Pine Knolls Alliance Church or an adult sponsor to secure the services of a licensed physician to provide the care necessary, including anesthesia, for my child(ren)’s well-being.

     

    Furthermore, I release Pine Knolls Alliance Church, together with the adults in charge of each event, from any and all claims resulting from injury or damage that may be sustained by said child(ren) while participating in Pine Knolls sponsored activities during the 2020-2021 ministry year (September 1, 2020 - August 31, 2021).

  • Clear Signature
  • This release will be valid for all Family Ministry activities during the 2020-2021 ministry year, unless a written request to terminate this release is received by Pine Knolls Alliance Church prior to the start of a particular event.  This includes, but is not limited to: Sunday morning, events / classes, Celebration Place, The Landing, Kids Club, CONNECT, Young Life, Summer Camp, and other special events. Furthermore, this shall serve as a release to use photos or likeness of named child(ren) in promotions and publications, both digital and in print unless a written request to the contrary is received. By providing your email and cell numbers you grant permission to be added to our communication lists.

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  • Child Information


  • Grade

  • School

  • Insurance Company

  • Policy Number

  • Physician's Name

  • Allergy, medical, or special needs information

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