2008- 2009 Adventure Club Registration Form

This is the Adventure Club on-line Registration Form for the 2008-2009 Adventure Club Session. We look forward to having your child participate with us this session.

To register please complete the entire form. This form must be completed by a parent or guardian and you will asked to attest to this at the bottom of the form. Thanks for your interest and God Bless!

Child's First Name: *

Child's Last Name: *

Child's Age: *

Birthday (mm/dd/yyyy):

Grade of School Child is in currently:

Allergies, Medical Conditions or Other Comments:

Parent's Name: *

Street Address: *

City, State and Zip: *

Phone Number(s):

Emergency Contact: *

Emergency Contact Phone Number: *

Church Affiliation :

Is your child allowed to leave the club alone?: *

Yes

Is there someone else who is allowed to pick up your child?: *

Yes

Alternative Pick up Name: :

Person completing this form: *

Parent Authorization: *

By submitting this form I attest I am the person named above and that I have the authority and do give my permission for the child named above to participate in Adventure Club . I understand that I or my designated alternate listed above must come inside the building to pick up my child unless I have indicated on this form that my child has my permission to leave the building unsupervised. I am aware that Junior High and High School students will have their opening session with all students at the Rossville United Methodist Church. Then for their class session, they will travel by foot to The Rock, which is a youth facility owned by the Rossville Church of the Brethren located across the street from their church. Submitting this form gives my child permission to walk to this facility for class. I agree that my child will be expected to remain with the group as they travel between the R.O.C.K. and the two churches for club functions. I also understand that from time to time Adventure Club or other participants will take pictures during activities. I hereby grant permission to use my child's likeness in a photograph in the organizations publications, including website entries to promote adventure club.

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