Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Add to email Mailing List for updates and communications *

Yes

No

Phone *

(###)

###

####

Allow Texts? *

Yes

No

Parent/Guardian Name

First Name

Last Name

Phone

(###)

###

####

Allow Texts?

Yes

No

Add to Mailing List for updates and communications

Yes

No

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Is this number a cell phone? *

Yes

No

Liability Release *

I understand that participation in this program is not without risk, and so release, forever discharge and agree to hold harmless Southern Heights Presbyterian Church, the staff and volunteers of this organization, as well as any parent organizations (Presbytery, Synod, General Assembly) from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred while my child is participating in the program. Further, I hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in the program. 
I also agree to hold harmless and indemnify said church, its directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful, or intentional acts of my child, including any expenses incurred by those acts. By checking the following box, I declare that I understand and am in agreement with these statements.

I agree

Transportation Release *

I give permission for the registered child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Southern Heights Presbyterian Church.

Yes

No

Photo/Video Release *

I give permission for Southern Heights Presbyterian Church to take and use photos and videos of my child/ren in church communications, publications and promotional materials, including (but not limited to), inclusion in the monthly newsletter, weekly hotline, posting to the southernheights.org website, facebook, twitter, and instagram pages.

Yes

No